Managemen komprehensif nyeri
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This document discusses various psychological approaches for managing chronic pain, including cognitive behavioral therapy (CBT), relaxation techniques, biofeedback, hypnosis, and motivational interviewing. It notes that CBT is the most common approach and aims to change maladaptive thoughts and behaviors. Relaxation methods like meditation, guided imagery, and biofeedback teach patients to control physiological processes linked to pain. The evidence for different approaches is reviewed, with hypnosis found most useful for acute rather than chronic pain. A conclusion drawn is that multidisciplinary programs combining several treatment components from a collaborative team are most effective for improving chronic pain outcomes.
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Managemen komprehensif nyeri
- 1. Azimatul Karimah (oe_tjie@yahoo.com) Konferensi Nasional I CLP Yogyakarta, 8-10 Maret 2013
- 2. Complex subjective experience Emosi (kecemasan, takut, depresi, marah) Perilaku (peran sakit, sbg hukuman, perilaku menghindar, perilaku belajar) Kognitif (makna nyeri, beliefs, harapan, perhatian, distraction, labelling, proses belajar) Somatic damage Pain
- 3. Goal (Sellinger et.al, 2011) 1. Pain Assessment from multiple source persons (patient, family, nurses etc) 2. Keep “aware” of biopsychosocial approach 3. Treatment plan 4. Outcome measurement identification 5. Education Multidicipline Pain Assessment
- 4. Multidicipline Pain Assessment ( Sellinger, 2011)
- 5. Biopsychososial model of Pain Management
- 6. Insight Oriented Approach Chronic pain is somatic presentations of emotional distress, and non-conscious factors Focus on : early relationship experiences that are reconstructed within the therapeutic relationship No controlled trial efficacy ??? Turk, Wilson, Swanson, 2011
- 7. Reinforcement in maintenance of pain behavior Ask, observe, and make inferences of behavior. “pain-related” behaviors communicated a message Avoidance of activity has a positive effect (negatively reinforcing) Corrective feedback “hurt” “harm” Respondent Conditioning Opperant Conditioning Turk, Wilson, Swanson, 2011
- 8. Reinforcement in maintenance of pain behavior (2) Respondent Conditioning • corrective feedback • exposure • quota-based exercise programs Opperant Conditioning • withdraw positive attention for pain behaviors, reinforcement of well behaviors. • active in setting treatment goals and follow through with recommendations • Efficacy good Turk, Wilson, Swanson, 2011
- 9. • Which behavioral technique was more effective ?? • Weak evidence that they were more effective when compared to usual care • Van Tulder et al. behavioral treatments, as compared to placebo or wait-list control, were moderately effective for low back pain intensity in over half of the studies they reviewed (van Tulder MW, Ostelo RWJG, Vlaeyen JWS, et al. , 2002 Behavioral treatment for chronic low back pain ) • Eccleston, et al. Determined: behavioral treatments were effective in reducing severity and frequency of chronic headache pain (Eccleston C, et.al. Pain 2002;99:157–65) Reinforcement in maintenance of pain behavior (3) Turk, Wilson, Swanson, 2011
- 10. CBT Stephen Morley (2011) Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges .PAIN 152 : S99–S106
- 11. CBT • Most common • Beliefs : unable to function because of pain, and helpless to improve the situation • Goals : realize that they can manage their problems, and provide them with skills to respond in more adaptive ways that can be maintained after treatment is terminated. • stress management + problem-solving, goal-setting + pacing of activities + assertiveness • Homework • Efficacy vs not beneficial Turk, Wilson, Swanson, 2011
- 12. 4 Component of CBT Maladaptive thought to coping thoughts and behavior learn and practice new pain management behaviors and cognitions solidifying skills and preventing relapse
- 13. Ex : Pain Diary
- 14. Motivational intreviewing Stage Target Contemplation acknowledge the risks associated with inactivity and passivity Goal : realize that the risks of inactivity outweigh the perceived benefits. Preparation helps the patient outline appropriate structured physical activities Action increase activity Maintenance Motivation and commitment Turk, Wilson, Swanson, 2011
- 15. Motivational intreviewing (2) • Providing motivational statements, • Listening with empathy, • Asking open-ended questions, • Providing feedback and affirmation, • Handling resistance
- 16. Relaxation Jensen, 2011; Turk, Wilson, Swanson, 2011
- 17. Meditation Trancendental meditation Mindfulness meditation Focus, concentration reframes the experience of discomfort ~ zoom lens ~ wide lens transcending the ordinary stream of thought attempting awareness of the whole perceptual field Less useful More useful
- 18. Biofeedback • pain is maintained or exacerbated by ANS dysregulation ~ the production of nociceptive stimulation • Objective : teach people to control over their physiological processes • Monitored : (Tan, Jensen, 2007; Turk, Wilson, Swanson, 2011) • skin conductance, • respiration, • heart rate variability for depression and pain, fibromyalgia • skin temperature for migraine • brain wave activity, • muscle tension for TTH
- 19. Biofeedback (2) • Mechanism ?? General sense of relaxation ?? Sense of control ??? • Nestoruic and Martin: all biofeedback methods were effective for chronic headaches (Nestoruic Y, Martin A. Efficacy of biofeedback for migraine:meta-analysis. Pain 2007; 128:111–27) Using rtfMRI to control activation in the rostral anterior cingulate cortex (rACC) ~ pain perception and regulation
- 20. Guided Imagery • To relax, achieve sense of control and distract from pains • Stand alone or used in conjunction with other treatment • Visualization or imagination • The most successful images involve all of the senses(vision, sound, touch, smell, and taste).
- 21. Hypnosis Three central component : 1. Absorption; involvement in central object of concentration 2. Dissociation ; experience be experienced consciously occur outside of conscious awareness 3. Sugesstibitily ; accept outside input without cognitive censoring or criticism • Patterson and Jensen, hypnosis has more utility in the treatment of acute pain than chronic pain (Jensen MP, Patterson DR. Hypnotic treatment of chronic pain. J Behav Med 2006; 29:95–124)
- 22. Hypnosis • The evidence for hypnosis was incomplete (Turk, Wilson, Swanson, 2011) • Hypnosis + CBT treatments = enhances the efficacy of the latter, arguing for combining hypnosis with CBT to improve clinical outcomes (Jensen, 2011)
- 23. Other Modalities • Education and Group Therapy • Anger Management • Assertive Communication • Perfectionism and Unrealistic Expectations • Cycle of Chronic Pain • Planning for Difficult Days • Personal Responsibility • Relationships and Chronic Pain • Physical Therapy • Occupational Therapy • Sleep hygiene • Lifestyle management
- 24. Conclussion • Meta-analyses, psychological treatments have modest benefits on improving pain, physical, and emotional functioning • A multidisciplinary program would be maximally effective, all of the above treatment-component team members need to be working collaboratively on a daily basis
Editor's Notes
- Assessment medis Vital sign patient self-report Karakter nyeri (lokasi, onset, pola, deskripsi, intensitas, perbaikan, perburukan, riw pengobatan) Dampak nyeri Goal Assessment perilaku Persepsi terhadap disabilitasnya Pain Dissability Index (PDI) Brief Pain Inventory (BPI) Fungsi emosi Coping mechanism Problem dengan mood (Beck Depression Inventory, Pain Anxiety Assessment Scale, dll) Fungsi psikosoial Membantu menetapkan target intervensi untuk perbaikan kualitas hidup Beliefs Kesiapan terhadap terapi
- Transcendental meditation requires concentration;it involves focus on any one of the senses, like a zoom lens, on a specific object. For example, the individual repeats a silent word or phrase (“mantra”) with the goal of transcending the ordinary stream of thought [182, 186]. Mindfulness meditation is the opposite of transcendental meditation in that its goal is attempting awareness of the whole perceptual field, like a wide angle lens. Thus, it incorporates focused attention and whole field awareness in the present moment. For example, the individual observes without judgment, thoughts, emotions, sensations, and perceptions as they arise moment by moment [183, 187]. Bonadonna proposed that individuals with chronic illness have an altered ability to concentrate: € therefore, transcendental meditation may be less useful than mindfulness meditation when one is sick [188]. Mindfulness meditation reframes the experience of discomfort in that physical pain or suffering becomes the object of meditation. Attention and awareness of discomfort or suffering is another part of human experience:€rather than be avoided it is to be experienced and explored [188]. Studies have found that mindfulness based interventions have decreased pain symptoms, increased healing speed, improved mood, decreased stress, contained healthcare costs, and decreased visits to primary care [182, 189]. Meditation has captured the attention of medicine psychology, and neurocognitive sciences. This is in part due to experienced meditators demonstrating reduced arousal to daily stress, better performance of tasks that require focused attention, and other healthbenefits [190, 191]. Lazar et al. found that long-term meditation in Western practitioners showed increased cortical thickness in areas related to somatosensory, auditory, visual, and interoceptive processing [190]. They found thickening in right Brodmann’s areas 9/10, which has been shown to be involved in the integration of cognition and emotion. Meditation may be useful for chronic pain patients due to the reciprocal relationship between stress and pain symptoms. igher alpha brain wave activity has been found to have beneficial health effects as well as promote a general sense of well-being [192]. Furthermore, gamma wave activity is the synchrony of areas of the brain
- Biofeedback is a self-regulatory technique. The assumption with regard to biofeedback treatment is that the level of pain is maintained or exacerbated by autonomic nervous system dysregulation believed to be associated with the production of nociceptive stimulation. The objective of biofeedback is to teach people to exert control over their physiological processes to assist in re-regulating the autonomic nervous system. When people are treated with biofeedback, they are attached by surface electrodes to equipment that is linked to a computer that transforms and records physiological responses. These monitored physiological processes may include skin conductance, respiration, heart rate, heart rate variability, skin temperature, brain wave activity, and muscle tension. The biofeedback equipment conveys physiological responses as visual or auditory signals that the person can observe on a computer monitor. In this way, the physiological information is “fed back”. With practice, individuals learn to control and change their physiological responses by learning to manipulate the auditory or visual signals by their own efforts. In addition to the physiological changes accompanying biofeedback, patients
- Recently, “real-time” functional MRI (rtfMRI) has been used as a sophisticated source of biofeedback to train participants to control activation in the rostral anterior cingulate cortex (rACC). This brain region is reputedly involved in pain perception and regulation. When the participants deliberately induced changes in the rACC, there was a corresponding change in the perception of pain [195]. The actual mechanisms involved in the success of biofeedback are still unknown; however, a general sense of relaxation is an important feature of biofeedback. It is not clear whether the alteration of specific physiological parameters putatively associated with pain is the most important ingredient of biofeedback compared to the broader relaxation and sense of control created.
- Guided imagery can be a useful method for helping people with pain to relax, achieve a sense of control, and distract themselves from pain and accompanying symptoms. This modality involves the generation of different mental images, evoked either by oneself or with the help of the practitioner. It overlaps with different relaxation techniques and hypnosis. Although guided imagery has been advocated as a stand-alone intervention to reduce pre-surgical anxiety and postsurgical pain, and to accelerate healing [196], it is most often used in conjunction with other treatment interventions such as relaxation and within the context of€CBT. With guided imagery, using the capacities of visualization or imagination, people are asked to evoke specific images that they find pleasant and engaging. In this way, a detailed representation that is tailored to the person can then be created. When patients with chronic pain are feeling pain or are experiencing pain exacerbation, they can use imagery with the goals to redirect their attention away from their pain and achieve a psychophysiological state of relaxation. The most successful images involve all of the senses(vision, sound, touch, smell, and taste). Some people, however, may have difficulty generating images and may find it helpful to listen to a taped description or
- Hypnosis has been defined as a natural state of aroused attentive focal concentration coupled with a relative suspension of peripheral awareness. There are three central components in hypnosis:€(1) absorption, or the intense involvement in the central object of concentration; (2) dissociation, where experiences that would commonly be experienced consciously occur outside of conscious awareness; (3) suggestibility, in which persons are more likely to accept outside input without cognitive censoring or criticism [197]. Hypnosis has been used as a treatment intervention for pain control at least since the 1850s. It has been shown to be beneficial in relieving pain for people with headache, burn injury, arthritis, cancer, and chronic back pain [198–200]. As with relaxation techniques, imagery, and biofeedback, hypnosis is rarely used alone in chronic pain although it has been used as a solo psychological model with some success with cancer patients [201]:€practitioners often use it concurrently with other treatment interventions. A meta-analysis suggests an overall benefit of the addition of hypnosis to non-hypnotic pain management strategies, although this may be mediated by a person’s level of hypnotic suggestibility [199]. Furthermore, there are discrepancies in the literature