Chronic pain: psychological formulation and MDT working: a COVID-19 pandemic reflective update

Chronic pain management is complex and often a challenge to manage. Patients' expectations are frequently at odds with the treatment outcomes which can be a significant source of distress. This is been further compounded by the significant impact of the coronavirus disease (COVID-19) pandemic with patients’ access to pain clinic services reduced in many areas. Clinical psychologists work as part of the multidisciplinary pain team to draw together information and develop a biopsychosocial understanding of how to support patients to live well while experiencing ongoing pain in the context of the COVID-19 pandemic. This article presents two alternative models for formulating and providing therapy for individuals experiencing chronic pain including consideration of the impact of the COVID-19 pandemic: cognitive behavioural therapy and acceptance and commitment therapy. Psychologically informed strategies to support healthcare professionals in their interactions with people with chronic pain are presented.     

Psychomotor and cognitive functioning in cancer patients

Psychomotor and cognitive dysfunction in cancer patients can be classified into two main categories according to etiology: disease-induced factors (metabolic disturbances, brain metastasis, pain, etc.) and treatment-related factors (drugs, antineoplastic therapy, etc.). In particular, the effects of chronic opioid administration in cancer patients have been subjected to investigations, and most studies have been engaged in assessment and treatment of the cerebral dysfunction. Early studies found that cancer patients in chronic oral opioid therapy had prolonged continuous reaction times, and that the opioids seemed to be mainly responsible for the prolongation. Significant dose escalations of opioids (≥ 30%) caused transiently impaired psychomotor and cognitive functions in cancer patients. Cancer patients in chronic oral opioid therapy did not achieve any advantages changing to epidural opioid therapy with regard to faster continuous reaction times and less pain.
Large doses of opioids are often required to control severe pain in cancer patients. As increased sedation and impaired psychomotor and cognitive functions often occur, a number of studies have investigated the use of amphetamine derivatives to counteract the sedative side-effects of opioid. These drugs seem promising during high-dose opioid therapy and their use may be particularly rewarding in poor opioid-responsive pain conditions such as incident and neuropathic pain.     

Cognitive behavioural treatment for essential hypertension: A controlled study

Sixteen patients with essential hypertension from the northwest of Spain were exposed to a three—four week baseline period and later divided into two groups of eight patients each. One of these groups was treated with a six-week cognitive behavioural programme based mainly on stress inoculation training and the other group was assigned to an attention—placebo condition based on individual regular contacts between the therapist and the patient, including discussions about the lifestyle of the latter but without any training on cognitive or behavioural strategies. After the six-week intervention period, and at a six months' follow-up, subjects treated with the cognitive behavioural programme showed a significantly higher reduction of diastolic blood pressure than patients exposed to the attention—placebo condition, considering measurements taken both at hospital and at patients' homes. Similarly, the group treated with cognitive behavioural therapy showed a significant within-group reduction over the measurement taken at hospital.     

Can we influence the neurological development and hair cortisol concentration of offspring by reducing the stress of the mother during pregnancy? A randomized controlled trial

The objective was to evaluate the effects of a stress management cognitive behavioural therapy followed during pregnancy on subsequent childhood on hair cortisol at birth and on neurodevelopment and Hair Cortisol Concentrations (HCC) at 6 months of age. The study sample included 48 pregnant women, divided into two groups: 24 women in the Therapy Group (TG) and 24 women who received standard pregnancy care (control group (CG); CG). To test the therapy efficacy, an evaluation of the HCC and psychological stress, psychopathological symptomatology and resilience was conducted before and after the treatment. The level of cortisol in their hair was obtained during pregnancy and that of their babies at birth. Six months after birth, a cortisol sample was taken from the hair and the babies' neurodevelopment was evaluated based on a Bayley-III test. The TG presented reductions in psychological stress and psychopathological symptomatology after treatment. On the other hand, the CG increased their cortisol concentrations between the pre and post intervention, remaining stable in the TG. Moreover, results showed that TG babies had lower cortisol concentrations at birth and obtained significantly higher cognitive and motor development scores at 6 months. These findings support that providing psychological care to pregnant women may not only have a benefit on these women's mental state, but may also benefit the neurodevelopment of their offspring.     

Current evidence does not support the routine use of cognitive behavioural therapy in total knee arthroplasty: A systematic review

BackgroundThere is a significant dissatisfaction rate in patients undergoing total knee arthroplasty (TKA), and poor mental health in patients is increasingly recognized as a major contributor to dissatisfaction. The aim was to review the effectiveness of cognitive behavioural therapy (CBT) in improving pain and functional outcomes of patients undergoing TKA and highlight important aspects that may be crucial for improvement.MethodsA systematic search was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they were randomized control trials that included patients undergoing unilateral or bilateral TKA, with CBT as an intervention compared against usual care, and reported outcomes in pain, knee function and any psychological outcomes as measured.ResultsEight RCTs were selected which included 683 participants. The timings of CBT delivery, profiles of therapists, and outcome measures reported varied across the studies. Overall, 3 studies reported significant improvement in pain outcomes, 3 studies reported significant improvement in functional outcomes and 5 studies reported significant improvements in psychological outcomes.ConclusionCurrent evidence does not support the efficacy of CBT as current literature is too heterogenous. Further studies with homogenous CBT methods are required to further ascertain the true relationship between CBT and postoperative outcomes of TKA. Future studies should consider the points set out in this review, such as the importance of revisiting CBTskills, providing individualized therapy, having a supervisory team to support the fidelity of interventions, and identifying which group of patients would best benefit from CBT.     

Chronic pain: psychological formulation and MDT working

Chronic pain is complex and often a challenge to manage. Patients’ expectations are frequently at odds with the treatment outcomes which can be a significant source of distress. Pain is best understood within the biopsychosocial model. Clinical psychologists work as part of the multidisciplinary pain team to draw together information and develop an understanding of how to support patients to live well while experiencing ongoing pain. This article presents two alternative models for formulating and providing therapy for individuals experiencing chronic pain; cognitive behaviour therapy and acceptance and commitment therapy. Psychologically informed strategies to support healthcare professionals in their interactions with people with chronic pain are presented.     

慢性疼痛的药物治疗

近年来，对慢性疼痛的认识及治疗都有了长足的进步。建立在循证医学和科学机制基础上的治疗正在取代单中心和以疾病为基础的经验性治疗。药物、理疗、精神—心理治疗和以神经阻滞、电刺激为代表的侵入性治疗是慢性疼痛治疗的四大支柱。本文复习常用的几大系列药物，非甾类消炎药、阿片类药、抗抑郁药、抗惊厥药、局部用药、曲马多、兴奋性氨基酸受体拮抗药以及合并用药问题。     

男性心因性性功能障碍的认知行为治疗(附个案报告)

目的探讨男性性功能失调的认知行为治疗。方法本文通过对1例男性性功能失调个案发生前后的心理社会环境包括认知因素、父母教养方式、个人成长中的不良经历、防御方式等与疾病过程的相互作用的分析,并结合个案,从学习理论、认知理论探讨了男性性功能障碍的病理心理机制,给予该患者的认知一行为综合疗法。结果患者精神心理症状缓解,勃起功能恢复止常。结论认知行为治疗在心因性性功能勃起功能障碍患者中的治疗作用应该引起重视。     

幻肢痛研究进展

幻肢痛的发病机制尚未完全阐明,药物治疗主要包括三环类抗抑郁药、抗惊厥药、NMDA受体拮抗剂、镇痛药、阿片类药物等,虽然以往研究证实上述药物对神经性疼痛有很好的疗效,但对幻肢痛的疗效仍存在争议,尚需更大样本研究。心理治疗、行为治疗疗效不确定,可能与逆转大脑皮质功能重组有关。外科手术由于损伤大、效果不明确及治疗过程复杂,患者不易接受。物理治疗似有较好的研究前景,但其疗效还需进一步验证。电休克治疗幻痛疗效明确且创伤小,有可能将成为幻肢痛治疗的有效手段。     

Feasibility of virtual reality-delivered pain psychology therapy for cancer-related neuropathic pain: a pilot randomised controlled trial

Virtual reality-delivered psychological therapies have recently been investigated as non-pharmacological management for acute and chronic pain. However, no virtual reality pain therapy software existed that met the needs of cancer patients with neuropathic pain. We created a bespoke virtual reality-delivered pain therapy software programme to help cancer patients manage neuropathic pain incorporating guided visualisation and progressive muscle relaxation techniques, whilst minimising the risk of cybersickness in this vulnerable patient population. This randomised controlled pilot study evaluated the feasibility, acceptability, recruitment rates and risk of cybersickness of this pain therapy software programme. Clinical outcomes including opioid consumption, pain severity, pain interference and global quality of life scores were secondary aims. Of 87 eligible cancer patients with neuropathic pain, 39 were recruited (47%), allocated to either the intervention (20 patients, virtual reality pain therapy software programme) or control (19 patients, viewing virtual reality videos). Four patients withdrew before the 3-month follow-up (all in the control group). Pre-existing dizziness (Spearman ρ 0.37, p = 0.02) and pre-existing nausea (Spearman ρ 0.81, p < 0.001) were significantly associated with risk of cybersickness in both groups. Patients in the intervention group reported less cybersickness, as well as tolerated and completed all therapy sessions. At 1- and 3-month follow-up, there were trends in the intervention group towards reductions in: oral morphine equivalent daily dose opioid consumption (−8 mg and −4 mg; vs. control: 0 mg and +15 mg respectively); modified Brief Pain Inventory pain severity (−0.4, −0.8; vs. control +0.4, −0.3); and pain interference (−0.9, −1.8; vs. control −0.2, −0.3) scores. The global quality of life subscale from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 was not significantly changed between groups at 1 and 3 months (intervention: −5, −8; vs. control: +3, +4). This newly created virtual reality-delivered pain therapy software programme was shown to be feasible and acceptable to cancer patients with neuropathic pain. These results will aid the design of a definitive multicentre randomised controlled trial.     

Combined use of hypnosis and emg biofeedback in the treatment of stress-induced conditions

Hypnotherapy has been used successfully in the treatment of stress-induced conditions. In this study the use of hypnosis is compared with the use of hypnosis plus EMG biofeedback in the framework of behavioural therapy. Twenty subjects, seven male and 13 female, mean age 37 years, suffering from stress and tension headaches were treated by hypnosis and behavioural therapy. Their results were compared with a group of 20 subjects, eight male and 12 female, mean age 33 years, who were given EMG biofeedback therapy in conjunction with the above treatments. There was no significant difference between the two groups on age, sex or social economic status and on stress and pain measures. Assessment was by measures on stress inventories and pain charts. The baseline measures were compared with the measures at week 12 and after 6 months. EMG biofeedback therapy was administered by placing electrodes on the subjects' forehead 30 ms prior to seeing the therapist. Both groups received 12 half-hour sessions of hypnosis and behavioural psychotherapy. The biofeedback group received an additional 30 ms on biofeedback apparatus. The results indicated that both groups showed significant gains, but the hypnosis and biofeedback group showed better results and reported that they found it easier to accept hypnotic training and self-regulation. The study indicates that EMG biofeedback has been useful in facilitating the treatment process and subsequent self-improvement training of the subjects. Follow-up study shows that both groups maintained most of their original gains.     

Chronic pain management after surgery

Chronic post-surgical pain is a common problem affecting between 2% and 10% of adults after surgery and a significant health burden. The development of chronic post-surgical pain involves multiple mechanisms including peripheral and central sensitization and nerve injury, thought to be the most significant factor. There are many risk factors including preoperative pain, chemotherapy/radiotherapy, surgical, psychological and genetic factors. The prevention of chronic post-surgical pain is challenging but progress is being made in identifying at risk groups, improved surgical technique and preventative analgesia including regional analgesia. Accurate diagnosis is essential for proper management, including identification of neuropathic pain. Management involves identifying any surgically or medically treatable cause, followed by pharmacological, psychological, physical and interventional management. It is essential for all clinicians involved in the care of surgical patients to have an awareness of chronic post-surgical pain, its prevention, diagnosis and treatment.     

Chronic pain management after surgery

Chronic post-surgical pain is a common problem affecting between 2% and 10% of adults after surgery and a significant health burden. The development of chronic post-surgical pain involves multiple mechanisms including peripheral and central sensitization and nerve injury, thought to be the most significant factor. There are many risk factors including preoperative pain, chemo/radiotherapy, surgical, psychological and genetic factors. The prevention of chronic post-surgical pain is challenging but progress is being made in identifying at-risk groups, improved surgical technique and preventative analgesia including regional analgesia. Accurate diagnosis is essential for proper management, including identification of neuropathic pain. Management involves identifying any surgically or medically treatable cause, followed by pharmacological, psychological, physical and interventional management. It is essential for all clinicians involved in the care of surgical patients to have an awareness of chronic post-surgical pain, its prevention, diagnosis and treatment.     

Clinical experience of long–term treatment with epidural and intrathecal opioids – a nationwide survey

Long–term use of spinal opioids to treat chronic severe pain is widely established. However, the indications, shortcomings and complications of the method have not been completely described. Experience with spinal opioids was analysed for the period 1979–1984 in a nationwide Swedish survey. Out of 93 anaesthesia departments, 69 used the method. Approximately 750 patients were treated with epidural morphine for an average duration of 124 days (3–450). Eighteen patients were treated with intrathecal morphine for an average period for 47 days (3–90). The intrathecal approach was used in all clinics because of failure of the epidural route. In only one department was the intrathecal approach used as the primary route of therapy, depending on the mechanism of pain. The highest daily morphine dose was 480 mg and 50 mg for epidural and intrathecal routes, respectively. The patients given the highest dosages were not necessarily those subjected to the longest treatment. The need for increased dosage seems to be related not only to changes in receptor sensitivity but also to changes in pain mechanisms. No case of threatening ventilatory depression was reported. Thirty–two departments had treated a few patients with chronic non–cancer pain conditions. Initial results were considered "excellent" in H departments, but at follow–up results were excellent in only one department. In addition to dislocation, occlusion of the catheters or leakage, injection pain was an obstacle to successful treatment. Pruritus, urinary retention, and local infections were not reported as significant problems, but one case of meningitis was reported.     

A mixed methods evaluation of a third wave cognitive behavioural therapy and osteopathic treatment programme for chronic pain in primary care (OsteoMAP)

IntroductionThe aim of this study was to evaluate the implementation of a 'third wave' cognitive behavioural therapy and osteopathic treatment programme (OsteoMAP) and explore its effect on patients with chronic musculoskeletal pain.MethodThis evaluation included a non-randomised before-and-after patient reported outcomes study with an embedded fidelity evaluation. Patients were seen for 1 h per week for six weeks. They received a questionnaire prior to receiving treatment and six months later. A purposive sample of patients were interviewed and clinical sessions were observed to evaluate competence and adherence to the intervention manual.Results208 patients were enrolled and 86% attended 3 or more OsteoMAP sessions. 82 students were trained to deliver the intervention under supervision. They were >90% adherent to the manual in 8 of the 12 domains measured. At baseline (n = 147), 69% of patients were female, 64% white and 77% reported pain for more than one year. At 6 months (matched pairs n = 63), there were clinically important changes of 58% in a composite score for pain, function, mood and coping (Bournemouth Questionnaire) and significantly higher psychological flexibility scores (difference in means 6.98 (95% CI 4.2,9.8)) (Acceptance and Action Questionnaire). No statistically significant change was seen in mindfulness (Freiburg Mindfulness Inventory), 30% of patients reported temporary symptom increases during the course but 95% were satisfied or very satisfied with their overall experience and outcomes.ConclusionsOsteoMAP was feasible, well received with some beneficial effects. Integrating psychological and osteopathic care shows promise and further research is warranted to assess effectiveness.     

Cancer Pain Management and Bone Metastases: An Update for the Clinician

Breast cancer patients with bone metastases often suffer from cancer pain. In general, cancer pain treatment is far from being optimal for many patients. To date, morphine remains the gold standard as first-line therapy, but other pure μ agonists such as hydromorphone, fentanyl, or oxycodone can be considered. Transdermal opioids are an important option if the oral route is impossible. Due to its complex pharmacology, methadone should be restricted to patients with difficult pain syndromes. The availability of a fixed combination of oxycodone and naloxone is a promising development for the reduction of opioid induced constipation. Especially bone metastases often result in breakthrough pain episodes. Thus, the provision of an on-demand opioid (e.g., immediate-release morphine or rapid-onset fentanyl) in addition to the baseline (regular) opioid therapy (e.g., sustained-release morphine tablets) is mandatory. Recently, rapid onset fentanyls (buccal or nasal) have been strongly recommended for breakthrough cancer pain due to their fast onset and their shorter duration of action. If available, metamizole is an alternative non-steroid-anti-inflammatory-drug. The indication for bisphosphonates should always be checked early in the disease. In advanced cancer stages, glucocorticoids are an important treatment option. If bone metastases lead to neuropathic pain, coanalgetics (e.g., pregabalin) should be initiated. In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management. In diffuse bone pain radionuclids (such as samarium) can be beneficial. Invasive measures (e.g., neuroaxial blockage) are rarely necessary but are an important option if patients with cancer pain syndromes are refractory to pharmacologic management and radiotherapy as described above. Clinical guidelines agree that cancer pain management in incurable cancer is best provided as part of a multiprofessional palliative care approach and all other domains of suffering (psychosocial, spiritual, and existential) need to be carefully addressed («total pain»).     

Optimising the psychological benefits of osteopathy

Osteopaths practise a physical method of treatment within a biopsychosocial model of illness. The most important risk factors for back and neck pain are psychosocial. Psychological treatments such as cognitive behavioural therapy, multidisciplinary rehabilitation and educational booklets have been successfully used to address these risk factors. Although osteopathy is a physical treatment, any reduction in distressing symptoms may have psychological benefits. To assess whether spinal manipulation was effective in improving psychological outcomes a systematic review of randomised controlled trials (RCTs) was carried out. The review identified 129 RCTs, 12 of which adequately reported psychological outcomes. The control interventions in these RCTs were grouped into either verbal or physical treatments. Six RCTs with a verbal comparator were combined in a meta-analysis and found that spinal manipulation improved psychological outcomes, with a mean benefit equivalent to 0.34 of the population standard deviation (SD) at 1–5 months; 0.27 of the SD at 6–12 months. Eight RCTs with a physical treatment comparator were combined in a meta-analysis and found a much smaller mean benefit of 0.13 of the SD in favour of manipulation at 1–5 months; 0.11 of the SD at 6–12 months. The nature of this psychological benefit was explored in one of these RCTs, which found that spinal manipulation improved back pain beliefs but not fear avoidance beliefs. The nature of this psychological benefit had also been explored previously in a qualitative study, which found that osteopathy patients reported improved understanding, reduced fear and a positive approach that encouraged exercise rather than rest. The psychological benefit could also be due to the placebo effect due to increased clinical contact, treatment preference, or the caring effect of the therapist. However, some authors argue that such effects are better described as part of the characteristic treatment effect of a complex intervention. If so, then the psychological benefits of spinal manipulation could be optimised by integrating cognitive behavioural principles into routine osteopathic practice. The benefits of such integrated care could be tested in future RCTs.     

Pain in pancreatic cancer: review of medical and surgical remedies

Pancreatic cancer is a malignant tumour with very poor prognosis and a chance for 5‐year survival is approximately 6%. One of the main symptoms of this neoplasm is pain, mostly of neuropathic origin, which significantly decreases the quality of life and impairs the functional activity of patients. The most common treatment of pain in pancreatic cancer is conservative therapy which is based on analgesic ladder rules established by the World Health Organization. Unfortunately, it is not always effective and it has many side effects that also can diminish patients’ quality of life. Invasive treatment of pain in pancreatic cancer includes mainly coeliac plexus block and sympathectomy, and both of them significantly reduce levels of pain and help to improve the quality of life. It is postulated that the place of those two invasive methods should not be at the final stage of treatment, but they can provide significantly better improvement of pain once instituted earlier (such as the first or second step of analgesic World Health Organization's ladder). The aim of this article is to review and assess the conservative as well as the invasive therapy in the management of pain in pancreatic cancer. It also presents brief insight into non‐medical methods of pain reduction, which can be supplementary to conservative and/or invasive treatment.     

Depression, anxiety, and substance use disorder in chronic pain

Patients with chronic pain frequently have depression, anxiety, and substance use disorder. It is important to recognize when these conditions are primary or comorbid as their presence will affect the response to interventions to address the pain, and will significantly affect the quality of life of the patient with chronic pain.The diagnosis of depression, anxiety, and substance use disorder may be complicated in such patients. The use of collateral observation from family members may be helpful to determine when there was a change in mood and level of function associated with the mood disorder versus the pain itself.The use of dual-action antidepressants may be most helpful in depression and chronic pain in the absence of depression. A variety of psychological treatments combined with medication approaches may improve the response. It will be important for the practitioner treating chronic pain to develop relationships with psychiatrists and psychologist that are familiar with the use of these medications, and the modalities of cognitive behavioral therapy, couples and family therapy, biofeedback, and EMDR.