NEUROPATHIC PAIN MINDFULNESS FOR CANCER SURVIVOR LIVING WITH CHRONIC

Transcription

1 MINDFULNESS FOR CANCER SURVIVOR LIVING WITH CHRONIC NEUROPATHIC PAIN By Patricia Poulin, Ph.D., C.Psych. Clinical, Health, and Rehabilitation Psychologist Associate Scientist, OHRI PRESENTED ONLINE FOR CIRPD, AUGUST 8, Affiliated with Affilié à

2 DISCLOSURE No conflicts of interest to disclose Major sponsors: 2

3 PLAN Chronic neuropathic pain (CNP) among cancer survivors the problem Examine the role of mindfulness in the management of chronic pain, including neuropathic pain (AWARE study) a potential solution Present preliminary data from a RCT of MBSR among breast cancer survivors living with CNP Discuss implications and future directions 3

4 PAIN 4

5 CHRONIC NEUROPATHIC PAIN Caused by lesion or dysfunction within nervous system Symptoms include painful sensations: Burning Electric shocks Tingling/numbness 5

6 NEUROPATHIC PAIN AMONG CANCER SURVIVORS Affects 30% to 60% of survivors Surgery Persistent post-surgical pain Chronic post-thoracotomy pain Phantom pain (e.g., phantom limb pain; phantom breast pain) Radiation Brachial plexus neuropathy Chemotherapy Chemotherapy-inducted peripheral neuropathy (agents e.g.: taxanes; platin) Malignancy Brown et al, 2014; Jung et al,

7 Often resistant to commonly prescribed analgesics; MEDICAL MANAGEMENT Interventional approach require access to specialists and may not be sustainable in the longterm; Even when optimal medical management is offered, some degree of pain will often persist Side effects for recommended pharmacological treatments are common 7

8 WHAT CAN WE DO? 8

9 COGNITIVE BEHAVIOURAL CONCEPTUAL MODEL Thoughts Beliefs, understanding, expectations Environment Emotions Fear; sadness; anger PAIN Behaviours What we do How we do it Physical Factors Fitness, posture, medications, tension, diet, energy level, etc. 9

10 MINDFULNESS - Defined as: The ability to maintain a non-judgemental awareness of our moment-to-moment experiences. (Kabat-Zinn, 1990) - Practicing mindfulness helps us develop a better understanding and acceptance of ourselves and our experiences; - Practicing mindfulness has an impact on our physiology (stress hormones, immune function, brain function), our emotions, and our thoughts; We can learn and practice mindfulness! 10

11 MINDFULNESS BASED STRESS REDUCTION 8 week, 2 hours per week + 1 day silent retreat minutes of home practice Foundations of mindfulness Psychoeducation about stress Various forms of mindfulness practice: Body Scan Yoga / Mindful Movement Sitting Meditation with various foci (breath, sensations, thoughts) Walking Meditation Mindful Eating Loving Kindness Meditation Mindfulness in everyday activities 11

12 PRIOR RESEARCH Mindfulness in Chronic Pain Literature - Moderate effect sizes for pain intensity, depression, anxiety, physical wellbeing and quality of life (see Veehof et al. 2011) Mindfulness in Oncology Literature - Several published meta-analyses; generally small effects for physical health and moderate effects of mental health; biological changes (e.g., shift away from pro-inflammatory state) Limited study in chronic neuropathic pain 12

13 COULD MBSR BE AN EFFECTIVE INTERVENTION FOR CNP AMONG CANCER SURVIVORS? - SETTING THE FOUNDATION 13

14 SUMMARY Cross-sectional survey of 78 cancer survivors (> 1 year post treatment) living with chronic neuropathic pain; Strong + correlations between pain intensity, neuropathic pain symptoms, pain catastrophizing, disability; Strong correlations between mindfulness and all of the above variables 14

15 MINDFULNESS MODERATES THE RELATIONSHIP BETWEEN PAIN INTENSITY AND PAIN CATASTROPHIZING Poulin et al.,

16 TREND SUGGESTING THAT MINDFULNESS MODERATES THE RELATIONSHIP BETWEEN PAIN INTENSITY AND DISABILITY Poulin et al.,

17 ~ 2/3 of participants interested In participating in study examining non-pharmacological Intervention! 17

18 CAN WE EFFECTIVELY INTERVENE? AWARE Study The Effect of an Inter-Disciplinary Program, Including Mindfulness-Based Stress Reduction, on Psychosocial Function, Pain Perception, Disability and Quality of Life in Patients with Painful Diabetic Peripheral Neuropathy Nathan et al. (accepted) 18

19 STUDY SUMMARY RCT comparing medical management + mindfulness-based stress reduction to medical management + waiting Adults (18 years and older) with diabetes, with good glycemic control, and painful peripheral diabetic neuropathy for > 6 months Primary Hypothesis: There will be 30% more responders ( 1 point improvement on the Brief Pain Inventory Interference Scale measured at 3-month post-treatment 19

20 MEDICAL MANAGEMENT Assessment by a nurse specialist with a pain specialist Review of medications that have been trialed Discussing with patients of any treatment options Implementation of treatment (if desired by patient) Patient has to be on stable regiment for a minimum of 2 weeks before being randomized to a group (generally means that patient enters group in about 4 weeks time) 20

21 CONSORT DIAGRAM AWARE STUDY Embargoed Image Nathan et al. (accepted)

22 RESULTS Significant reductions in pain intensity in the treatment group. Significant reductions in pain interference in the treatment group. Embargoed Image Nathan et al. (accepted) 22

23 RESULTS MINDFULNESS MEDIATES TREATMENT EFFECTS a 1 = 9.08*** Pain Catastrophizing b 1 = Group c l = 1.68 ** Pain Interference a 2 = *** Mindfulness b 2 = -1.63* Carson, A

24 CAN WE EFFECTIVELY INTERVENE? IN-DEPTH STUDY The Effect of an Inter-Disciplinary Program, Including Mindfulness-Based Stress Reduction, on Psychosocial Function, Pain Perception, Disability and Quality of Life in Breast Cancer Survivors with Chronic Neuropathic Pain 24

25 METHOD RCT with 108 women breast cancer survivor comparing Medical management Medical management + MBSR Inclusion Criteria: - Women aged 18, working knowledge of French or English - Previously treated for breast cancer ( 1 year post active treatment) - Average pain intensity (one week VAS) 4 - Not pregnant or breast feeding (change in medications may be proposed) Primary Hypothesis: There will be 30% more responders ( 1 point improvement on the BPI-I measured at 3-months post-treatment 25

26 SECONDARY OUTCOMES Pain intensity Neuropathic pain symptom inventory Depression Profile of Mood States Perceived Stress Quality of Life (SF-12v2) 26

27 SUB-STUDIES Cognitive effects of MBSR collaboration Dr. Barb Collins (analyses in progress) Changes in bio-markers of stress and immune function collaboration Dr. Laurie Ma (analyses in progress) Change in brain structure and activity during specific tasks (fmri) collaboration Dr. Andra Smith (completed) 27

28 MEASUREMENT TIME POINTS Participants complete questionnaires, provide blood and hair samples at 4 time points : - Before medical treatment - After medical treatment - After MBSR - At 3-month follow-up Cognitive Testing will be done - After medical treatment - After MBSR - At 3-month follow-up fmri - After medical treatment - After MBSR 28

29 DEMOGRAPHICS - REPORTING ON 30 PATIENTS Age = 52.1 (10.7) Ethnic background = 82.0% caucasian Employment status = 40% full time employment Post-secondary education = 74% Average Pain Interference = 4.5 Average Pain Intensity =

30 BPI-INTERFERENCE SCALE Embargoed Image 30

31 BPI-INTENSITY Embargoed Image 31

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33 NEUROIMAGING 1 hour scanning session High resolution structural scan fmri Emotional Stroop Task fmri Resting State Diffusion Tensor Imaging Smith et al. (in preparation)

34 NEUROIMAGING 1 hour scanning session High resolution structural scan fmri Emotional Stroop Task fmri Resting State Diffusion Tensor Imaging Smith et al. (in preparation)

35 SUMMARY Preliminary evidence suggests but it is too early yet to say definitively that MBSR is effective in reducing disability and improving QOL among cancer survivors living with CNP MBSR had a significant effect on brain activity during a cognitive task that engaged emotional, attentional and interference processes. MBSR reduced activity in brain regions of the pain matrix involved in rumination, sensation, body representation, inhibitory control, selfregulation, emotion Empirical evidence of the potential for this nonpharmacological means to improve quality of life in these women. Smith et al. (in preparation)

36 QUESTIONS THAT REMAIN TO BE ANSWERED Are their specific mindfulness practice that are particularly useful or not useful for cancer survivors living with CNP Are their people who benefit more from mindfulness-based interventions than others? And might a CBT-based intervention be better for them? Does timing of intervention matter? How can we increase accessibility to these interventions? COMPASSION Study

37 CONCLUSION Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom. Viktor E. Frankl

38 ACKNOLWEDGMENT Andra Smith - Neuroscientist Heather Romanow, coordinator & manager Yaad Shergill, coordinator Eve-Ling Khoo, research assistant Rebecca Small, medical student Taylor Hatchard, graduate student Ola Mioduscewski, graduate student Our study participants! 38