Transcript Slide 1

Chronic Pain is a demoralizing situation that confronts the sufferer with not only
the stress created by the pain but with many other ongoing issues and difficulties
compromising all aspects of their life, leading to increase emotional distress or
suffering.
As a result, unrelieved pain is a burden on the societal level by the way of healthcare
expenditures disability benefits lost productivity
THE NEED FOR AN ALTERNATIVE DISEASE
MODEL
The biomedical model of pain relates back to Descartes' 17th-century model.
 This assumes that people's reports results from a specific disease state representing a
disordered biology
 However, it is generally understood that the presence and extent of physical pathology
is not sufficient to account for all the reported physical symptoms by patients.
 Physical pathology does not always account for or predict the severity of pain and /or
level of disability
Medical model has a dichotomous view with regard to pain and symptoms being
either somatogenic or psychogenic
 Hence from this model once the underlying pathology has been addressed other
symptoms such as sleep issues, depression psychosocial disability and pain in general
should diminish.
 However this is not always the case
 It may be an issue that these secondary conditions as they call them may already be
pre-existing and converge with the pain cause or cause of pain
So what can account for the subjective varied expressions and experience of pain
 This inherently takes into consideration a Gestalt approach
The biomedical model is been criticized for not being able to account the
psychological psychosocial variables and their relationship with disease and
illness.
In fact as related to chronic pain so that such conditions like fibromyalgia and TMJ
don't fit neatly into the biomedical model
 In fact they are accompanied by a manifestation of widespread suffering preoccupation
and disability and possibly the adoption of sick role (Parsons, 1958).
THIS HAS RESULTED IN THE GATE CONTROL
THEORY OF PAIN IN 1968
This theory is the first attempt to combined the physiological and psychological
factors in order to develop integrative model
Differentiates three systems related to the processing of nociceptive stimulation
 Sensory – discriminative
 Motivational – effective
 Cognitive – evaluative
 NOTE: By emphasizing the CNS mechanisms, this theory provides a physiological
basis for the role of psychological factors in chronic pain.
 According to this theory, peripheral stimuli interact with cortical variables such as
mood and anxiety in the perception of pain.
THE GATE CONTROL THEORY OF PAIN
All of which contribute to the experience of pain
This theory considers somatic and psychogenic factors as potentiating or
moderating effects
This model experiences pain as an ongoing sequence, largely reflective in nature of
the onset, but modifiable even in the early stages by a variety of excitatory and
inhibitory influences as well the integration of ascending and descending CNS
activity.
Because this theory considers multiple systems continuously interacting, the
potential for the shaping of the pain experience is implied
Physiological details of this model has been challenge since it's beginnings in 1965
but it has demonstrated to be flexible and accommodating of new information.
THE NEUROMATRIX THEORY OF PAIN
Mel Zack suggests that the complex neural matrix relationship between the body
and the self
As such, it is believed that this is a genetic predetermined relationship or factor, but
it could be modified by sensory experience and learning leading to a dynamic
matrix.
On the significantly important point from this theory is that the nerve impulses are
hypothesized to be triggered either by sensory inputs or centrally independent of
any peripheral stimulation.
THE NEUROMATRIX THEORY OF PAIN
This theory takes into account that when an organism is injured there is an
alteration in the homeostatic regulation.
 This deviation from the normal status stressful and initiates a complex of hormonal and
behavioral mechanisms designed to restore homeostasis.
 This reminds me a little bit of diabetes stress-induced diabetes while in the hospital.
 Prolonged stress in ongoing efforts to restore homeostasis can suppress immune system
and activate the limbic system
THE NEURAL MATRIX THEORY
 The neural matrix theory is an extension of the GCT model by essentially integrating it
with Hans Selye theory of stress
 This limbic system has an important role in emotion, motivation and cognitive
processes
 Prolonged activation of the stress regulation system can lead to a predispostion for the
development of different chronic pain states.
 As such, they propose that pain suppression can be produced by sensory- affective
processes as well as activation of the endogenous opiates system.
 Therefore, the cumulative effects of stress that has preceded are concomitants with the
current stress may account for the large variation in individual responses.
 In this way, this theory incorporates the pain sufferers prior learning history to shape
the new matrix by influencing interpretive processes and individual physiological
behavioral response patterns
 A new stressor may amplify base line stress and related efforts of homeostatic
regulation.
 Prolonged stress augments tissue breakdown as the body continues to attempt to
return to its normal state.
 This theory proposes a diathesis stress model in which predispostional factors
interact with an acute stressor.
 A growing body of research in animals suggests that repetitive or chronic
nocicpetive input can result in structural and functional changes that may cause
altered perceptual processing and contribute to pain chronicity (wolf & mannion,
1999)
BIOPSYCHOSOCIAL PERSPECTIVE
In this section, they differentiate disease from illness
 Disease being an 'objective biological event' that involved disruption of specific body
structures or organ systems caused by pathological, anatomical or physiological
changes.
 Illness is" subjective experience or self attribution that a disease is present"
 As such, illness has multidimensional in that includes the manner in which the pt,
family and society perceive and respond to symptoms.
 This is similar to the distinction between pain and nociception
 What is the difference?
Biopsychosocial perspective includes the disease and illness perspective
It perceives pain as a dynamic process over time.
BIOPSYCHOSOCIAL PERSPECTIVE
 It needs to be perceived or studied or assessed longitudinally
 Be sensitive to the multifactorial processes that have a reciprocal interplay
Psychological factors may influence biology by affecting hormone production and
processes as well as stimulating the autonomic nervous system
The behavioral aspects can also affect by the way of deconditioning because of
refraining from engaging in normal behaviors are tasks
Hallmarks of the biopsychosocial perspective is that it takes into consideration
 An integrated action
 Reciprocal determinism
 Development and evolution
SUPPORT FOR THE IMPORTANCE OF
NONPHYSIOLOGICAL FACTORS
History demonstrates many cases in which there has been interventions that relieve
pain with no clear physiological or medical basis or understandable underlying
mechanism.
It was only until the end of the 19th century that curiosity and research began to
explore more clearly these mechanisms
Even though there wasn't clear underlying physiological mechanisms, these
practices demonstrated to have some effect.
 Hence, the idea of placebo effects or psychological cures
 Placebo- from nothing is happening to something extraordinary
Fitzpatrick, Hopkins, and Harvard -Wats (1983) did a study with headache patients
treated with pharmacological preparations. They concluded that although a
large number benefited from the drug treatment most improvements appear to
be unrelated.
SUPPORT FOR THE IMPORTANCE OF
NONPHYSIOLOGICAL FACTOS
Biofeedback also demonstrates benefits with pain but the effects may be unrelated to
modification a physiological activity ( see text for literature)
Deyo, Walsh, and Mattin (1990) study patients with intractable low pain low back
pain for four years. They chose this population because of the duration of
symptoms which would suggest minimal improvement in the absence of an
effective treatment. However these patients to demonstrate significant
statistically significant improvements but the same results were produced with
sham interventions suggesting that the treatment effects were not related to
physiological mechanisms
SUPPORT FOR THE IMPORTANCE OF
NONPHYSIOLOGICAL FACTOS
Greene and Laskin (1974) and TMD Temporomanidular disorders TMJ- study
Study focused on applying diverse set of treatments which included medications,
tranquilizers, physical exercises, intro oral appliances, injections, physical
therapy, psychological counseling, including various placebo effects in her
drugs, bite plates, mock equilibration of the bite for 6 months to 8 years
 All treatments were provided with reassurances, explanation for self-management and
sympathetic understanding
 92% of the patients had no or only minor recurrences of Symptoms, this suggest that
the nonspecific factors are also important not that these disorders are psychologicallybased but that they may be maintained by non-physiological factors
SOCIOCULTURAL FACTORS
Beliefs about illness and health care treatment along with providers is based on
previous experience or cultural beliefs
 This can lead to expectations that affect participation
 Hence, the practitioner patient relationship is significant
 Therefore your clear sense of self as a clinician and goals and treatment creates
perhaps a reciprocal system
 The textbook talks about several authors noting the importance of social cultural
factors and sex differences in beliefs about how they respond to pain
SOCIOCULTURAL FACTORS
Social learning mechanisms one aspect of pain behaviors that has been studied is
whether expressions of pain distress and suffering can be learned through
observational learning.
 Richard (1988) found children whose parents had chronic pain chose more pain related
responses to scenarios presented to them and were more external in their locus of
control versus children with healthy parents.
Operant learning mechanisms Fordyce (1976) contributed significantly to the idea
of how environmental factors can shape these pre-existing beliefs into pain
behaviors.
 Hence behavioral manifestations of pain rather than pain are central in operant
formulation
 These behavioral manifestations are Hughes or clues to the internal experience or
shaping that has taken place
SOCIOCULTURAL FACTORS
 People exposed the stimulus that is adversive immediately withdraw or attempt to
escape the noxious sensation.
 These behaviors are observable and therefore enforceable
 Positive reinforcement will increase in the lobby would persist
 Whereas no attention will decrease and diminish behavior
Lets distinguish the two again
SOCIOCULTURAL FACTORS
 Operant conditioning (or instrumental conditioning) is a type of learning in which an
individual's behavior is modified by its antecedents and consequences; the behavior may
change in form, frequency, or strength.
 refers to "an item of behavior that is initially spontaneous, rather than a response to a prior
stimulus, but whose consequences may reinforce or inhibit recurrence of that behavior".

 Classical conditioning (also Pavlovian conditioning or respondent conditioning) is a mode of
learning that occurs when a “Conditioned Stimulus” (CS) is paired with an “Unconditioned
Stimulus” (US) that causes an organism to exhibit an automatic "Unconditioned Response"
(UR) to the US.
 After pairing is repeated (some learning may occur already after only one pairing), the organism
exhibits the UR in response to the CS when presented alone. At this point, the UR is then known
as the "Conditioned Response" (CR) to the CS. Usually, the CS is a neutral stimulus (e.g., the
tone of a tuning fork), the US is biologically potent (e.g., the sight of food) and the UR to the US
(which becomes the CR to the CS) is a reflex response (e.g., salivation). The CR is the learned
response to the previously neutral stimulus CS.
CLASS EXERCISE Operant conditioning and Pain Behaviors
SOCIOCULTURAL FACTORS
Operant learning
 A pain behaviors such as limping can be reinforced positively by the attention of a
spouse
 there can also be negative reinforcement by the way of avoiding to do any activity so
there is an increase of avoidance because there is pain and therefore the pain subsides
 additionally there may be increase pain medication in order to decrease the adverse
the stimulus
 This approach does not concern itself with the initial cause of etiology but simply the
behaviors sustained over time
SOCIOCULTURAL FACTORS
 there has been literature since the 70's to support this approach
 significant literature supports that pain behaviors and well behaviors could be increase
with verbal reinforcement and by setting exercise quotas
 Gaylor (1980) demonstrated that patient reported different levels of pain when they
knew that they were being observed
 is this manipulation
 or is this once we are observed were attempting to communicate our internal
experience for someone else to clearly understand it
SOCIOCULTURAL FACTORS
 consider the cough at a doctor's office once you have major appointment not being
the same as the night before yet we may try to enhance it to demonstrate that it's
there
 solicitous others versus non-solicitous others increases pain reports, why
respondent learning
 so despite there being an operant conditioning experience but it may have been
initiated via classical conditioning
 Linton (1985) discussed how avoidance of activities was related more to the anxiety
about having pain than the actual pain so there is a conditioned stimulus-
SOCIOCULTURAL FACTORS
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 WHICH IS THE CONDITIONED STIMULUS?
Therefore classical conditioning can be followed by operant conditioning ( see text
page 11 first column bottom)
Initially in acute pain it may be useful to reduce movement but eventually you do need
to begin to do successive approximations or desensitization
 teaching how to manage the sympathetic activation with relaxation and pain
management is helpful to buffer and moderate the operant learning that can take
place
prediction of pain promotes pain avoidance and over prediction
promotes excessive avoidance but people who repeatedly engage in behaviors that
produce less pain than predicted will likely make adjustments and subsequent
expectations which will eventually become more accurate accurate predictions tend to
lead to decrease avoidance behaviors
COGNITIVE FACTORS
idiosyncratic beliefs and appraisals and coping methods become critical beliefs
about pain
certain beliefs may lead to maladaptive coping, exacerbation of pain increased
suffering
It can do otherwise as well consider someone with religious schemas.
 The suffering may be perceived as the cross that I bear
Individuals that see their pain is in unexplainable mystery tend to suffer more
 personal example with physical therapy and low back pain
beliefs can directly affect mood which in turn can affect muscle tension and
production of endogenous opioids
These belief systems as they are constantly stimulated by a chronic noxious
stimulant may be altered; therefore affecting how we label a threshold for a
noxious stimulus allowing us to become hypersensitive
COGNITIVE FACTORS
Hence, people with chronic pain will tend to refrain from engaging in certain
activities because they have relabeled their threshold so as to be distressful in
engaging in activity because it may stimulate discomfort.
Once cognitive structures based on memories and meaning form, they tend to
become stable and difficult to modify
Many additional pain treatment outcome studies support the idea that reducing
negative appraisals is one way to reduce the pain and associated suffering
Simultaneous accomplishment of muscle tension reduction and lowering reported
pain convinces patients that muscle tension and subsequent pain could be
controlled
BELIEFS ABOUT CONTROLLABILITY
many studies support the control of an aversive stimulus leads to decreased impact
page 15
 Conversely, expectation of uncontrollable pain may cause nociceptive input to be
perceived as greater
 Flor & Turk (1988) discovered in this study of pain related thoughts and sections of
personal control pain severity disability levels of people low back pain and arthritis
the general and situation specific convictions of uncontrollable pain and
helplessness were more highly related to pain and disability and were diseaserelated factors
SELF EFFICACY
Closely related to the sense of control is self-efficacy which is the belief of conviction
that one can successfully take a course of action to produce a desired outcome
 Efficacy judgments are based on four sources of information regarding one's
capabilities, in descending order:
 One's own past performance at a similar task
 The performance accomplishments of others we proceeded to be similar
 Verbal persuasion by others that one is capable
 Perception of one's own state of physiological arousal
SELF EFFICACY
 Hence, encouraging patients to undertake subtasks it increasingly difficult for close
to desire behavioral repertoire can create performance mastery (this can also be
seen as successive approximations)
 Cioffi (1991) has suggested at least four psychological processes that may be
responsible for the association between self efficacy and behavioral outcomes
 As self-efficacy is perceived to be decrease anxiety is illogical arousal, the person
may approach a task with less distressing physical information
 A person with high self-efficacy is able to willfully distract attention from
potentially threaten physiological sensations
 the efficacious person perceives and was distressed by physical sensations but
simply persist phase (stoicism)
 Physical sensations are neither ignored nor necessarily distressing, but rather a
relatively free to take on broad distributions
COGNITIVE ERRORS
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catastrophe rising
over generalizations
personalization
selective abstraction
Coping
 Studies of so that I could cook strategies such as efforts to function in spite of pain
to disturbance of from pain like in the case of self-efficacy is associated with more
adaptive unction. While passive coping strategies such as dependent on others to
student activities pain and depression.
Affect the factors
 According to Romano and Turner (1985) 40 to 50% of chronic pain patients suffer
from depression
 The majority of cases this is in reaction to their pain not before
 Those individuals that can retain some sense of control despite pain not become
depressed
 Anxiety Is commonplace for chronic pain
Anger has been widely observed patients with chronic pain
In a study Summers et al (1992) they found that spinal cord injuries patients’ anger
and hostility explained 33% of the variance in pain
 However, pain is exacerbated by anger
 One reasonable possibilities that it exacerbates pain by increasing autonomic
arousal