MBCT For Pain Pilot Open Mind Partnership
Context It is estimated that medically unexplained physical symptoms are the main reason for between 15% and 19% of GP consultations in the UK*. Furthermore up to 70% of people suffering with MUPS will also suffer from depression and/or anxiety disorders*.
*. However, as recognised in the Medically unexplained symptoms positive practice guide published by IAPT in 2008, mental health services have not been successful in engaging with patients experiencing MUPS, as patients often do not perceive their condition to be related to mental health problems.
Cost of MUPS in the UK In 2010 the Economics Policy Unit and the Centre for Mental Health stated that, incremental health care cost incurred by somatising patients is estimated to be 3 billion. This represents approximately 10% of total NHS expenditure on these services for the working-age population in 2008-2009. The cost of sickness absence and decreased quality of life associated with these patients amounts to over 14 billion
Chronic pain, MUPS, IAPT The majority of people with MUPS have chronic or persistent pain as part of their symptom spectrum. One or more types of pain such as back pain, joint pain, extremity pain, headache, abdominal and pelvic pain are present in most cases. The purpose of pain management services is to help patients with chronic pain, for whom traditional disease centred therapies have failed, with the emphasis on regaining quality of life *
The National Pain Audit Approximately 72% of people presenting to pain clinics are of working age. The majority of people attending pain clinics reported they were unable to work or had had to cut their hours. When reporting on quality of life, the inability to work and loss of enjoyment of life were the highest scoring problems associated with pain when using the Brief Pain Inventory.
Current Psychological Approaches for Pain Management - Outcomes Psychological Approaches to unexplained or resistant pain have been shown to improve reported well-being and function by between 25%-45%.
Pain definition Pain is a subjective experience that can be perceived directly only by the sufferer. It is a multidimensional phenomenon that can be described by pain location, intensity, temporal aspects, quality, impact and meaning. Pain does not occur in isolation but in a specific person in psychosocial, economic and cultural contexts that influence meaning, experience and verbal and non-verbal expression of pain. NIH Consensus Development Conference
Pain Theories Pre-Cartesian Mysterious/magical Cartesian Injury-based model Gate Control Theory Makes link with cognitive/behavioural processes mediating pain experience Neuromatrix Theory Melzack 1996
Pain Gate Theory
Pain as a Multi Dimensional Experience
The Neuromatrix theory Each person has a genetically built-in network of neurons called the "body-self neuromatrix. Just as each person is unique in physical appearance, each person's matrix of neurons is unique and is affected by all facets of the person's physical, psychological, and cognitive makeup, as well as his or her experience. Thus, the pain experience does not reflect a simple one-to-one relationship between tissue damage and pain.
The service users Journey Pain experience following acute injury/disease process or gradual onset due to chronic disease Chronic pain is continuous, long-term pain of more than 6 months or after the time that healing would have been thought to have occurred in pain after trauma or surgery. GP at some point refers to Pain Clinic Some service users benefit others discharged with unchanged pain experiences? Proportion Service user attends GP frequently on-going pain, low mood, anxious, helpless and hopeless, varying degrees of functional, occupational, social/interpersonal impairment GP refers to IAPT
MUPS and Pain Management Programme vs MBCT Long term conditions IAPT Meeting Dr Rob Hampton GP & Clinical Lead March 22nd 2013
What are the stories and profiles of people who choose and do/don t benefit from PMP or MBCT?
Fit for Work Service and long term pain Pain as significant barrier 274 (1 in 4) Identified Pain as the only issue 123 (1 in 2) Perceptions of pain addressed as key factor for the return to work 89 (1 in 3) Undiagnosed neuropathic pain (PainDetect >18, LANSS > 12 and treatment response) 20 (1 in 13) Pain medication changed 19 (1 in 13) New CFS/Fibromyalgia cases 23 (1 in 12)
MUPS with pain component Chronic pain is a frequent MUPS Research evidence for Pain Management Programme and MBCT Can we identify the best intervention for the person? What are the best outcome measures for success? Would personal preference be the best predictor? Can HCP guide the choice?
Evidence based Guidelines 81/204 Pain Services offer this (National Pain Audit 2012) Significant variation Usually Physiotherapist and Psychologist OR Psychology Assistant and OT. Expert Patient 30-40% improvement in reported wellbeing and function (British Pain Index) 6-8 sessions
Pain Management Programmes to improve the physical, psychological, emotional and social dimensions of quality of life of people with persistent pain, using a multidisciplinary team working according to behavioural and cognitive principles. All staff use cognitive behavioural principles to deliver their component/s of the PMP. Central and peripheral sensitisation Deconditioning
Pain Management Programmes Acceptance Pacing Goal setting Relaxation/breathing Graded exercise strength and stretching Set back plans Reduce medication and passive treatment Team work & support
Assessment pathway; referral to intervention
Assessment by Fit for Work Service
Pain Management Programme
Dr Rob Hampton GP & Clinical Lead March 22nd 2013 What are the stories and profiles of people who choose and do/don t benefit from PMP or MBCT?
MBCT approach Buddha 6th century BC MBSR, John Kabat-Zinn, 1979 MBCT, Segal, Teasdale, Williams, 2000 NICE guidelines 2004, 2009 Meditation-based
Modes of Mind Links with John Teasdale s work and three modes of mind Mindless Emoting: I am a failure ; emotional mind Conceptualising Doing: why am I a failure? ; rational mind Mindful experiencing Being: I m having the thought that I m a failure ; wise mind
Mindfulness Definition In clinical literature it has come to mean the awareness that emerges as a result of cultivating 3 related skills (being mode): Intentionally paying attention to moment by moment events Noticing habitual reactions to these events, often characterised by aversion (Rumination/Suppression) Responding to events and our reactions to them with an attitude of open curiosity and compassion Williams, 2008
MBCT & Rumination This pain is too much I can t cope I can t do anything right I m useless What's wrong with me? Recounting Pain experiences Crystal-ball gazing
Stabilising Attention SHIFT ENGAGE DISENGAGE STAY DISENGAGE STAY TIME
Raising Awareness moving toward discomfort
Active components to MBCT & pain reduction Rumination: A particular style of self-critical, selffocused, repetitive, negative thinking. Experiential avoidance: An attempt to remain out of contact with the direct experience of painful thoughts, emotions and body sensations. Meta-Cognitive shifts thoughts experienced as mental events rather than being perceived as me or truth (Teasdale)
MBCT for Pain 8 week course Key exercises: Raisin exercise Body Scan Mindful movement Awareness of routine activities Thoughts and feelings exercise Diary of pleasant and unpleasant events Up to 15 participants 2 facilitators