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CBT for chronic pain: state of the art

Outline. What is CBT?How has it been applied to chronic pain?What's the evidence?What needs to happen next?. A current usage of the term. ?The term CBT varies widely and may include self instructions ? relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about

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CBT for chronic pain: state of the art

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    1. CBT for chronic pain: state of the art Stephen Morley Plenary to the British Pain Society 2nd April 2009

    2. Outline What is CBT? How has it been applied to chronic pain? Whats the evidence? What needs to happen next?

    3. A current usage of the term The term CBT varies widely and may include self instructions relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about pain and goal setting varying selection of these strategies embedded in a more comprehensive pain management program that includes functional restoration, pharmacotherapy, and general medical management.

    5. The issue of diagnosis Does (medical) diagnosis matter or can we lump chronic pains together?

    6. Cumulative trials over years

    8. The effect size

    9. CBT vs active treatment

    10. Hoffman et al 2007 - back pain

    11. Eccleston et al 2009

    12. Effectiveness

    13. ACT programme at Bath

    14. The case of the shrinking effect size Bigger and better trials less bias, better quality Poorer treatment implementation lower doses, less skill, less specific fidelity More difficult, severe patient problems Less precise formulation of the problem vague specification of CBT

    15. Trial quality Bigger and better trials less bias, better quality

    16. Quality scale for psychological treatment trials

    17. Trial quality over time

    18. Effect size and quality

    19. Methodological quality

    20. Size matters

    22.

    23. Treatment implementation Poorer treatment implementation lower doses, less skill, less specific fidelity

    24. Trial quality over time treatment

    25. Is there a model, or, whats in the tin?

    26. Assessing treatment implementation & fidelity

    27. Treatment implementation Poorer treatment implementation lower doses, less skill, less specific fidelity Formal evidence is largely absent We havent done the trials with robust methodology Impressions therapist training & supervision often not reported Fidelity / competence probably inadequately measured

    28. More difficult, severe patient problems Evidence not fully evaluated

    29. Less precise formulation of the problem Vague specification of CBT and problem of pain

    30. Remember this . The term CBT varies widely and may include self instructions relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about pain and goal setting varying selection of these strategies embedded in a more comprehensive pain management program that includes functional restoration, pharmacotherapy, and general medical management.

    31. General protocol in CBT Principles Collaborative and consultative engagement Active practice of skills Education about chronic pain and its treatment Goals Improve physical fitness Reduce disability (Re) introduction to work Increase effective /adaptive problem solving Reduce pain related fear Reduce pain related depression

    32. Principles Do you use behavioural principles? Analysis of antecedents, behaviours and consequences Setting conditions Discriminative stimuli Identify reinforcers Contingency management Do you use cognitive therapy principles? Identify core non-functional beliefs e.g. if I move I will harm myself Design individualised behavioural experiments to test belief behaviour links

    33. Fear-Avoidance influences on behaviour

    35. Whats next? Improve trial quality some simple changes Size, implementation Refine whats in the tin develop more focussed and testable models

    36. The evidence cycle not a one-way street Efficacy studies Randomised Controlled Trials Evidence-based practice as policy Practitioners Practice-based evidence Effectiveness studies Routine Clinical Treatment Practitioners

    37. Two more issues Can we develop dichotomous outcomes - and how much change is required? Can we use trials to benchmarking clinical programmes?

    38. Turning continuous measures into dichotomous ones

    39. Turning continuous outcomes into dichotomous ones

    40. Outcome categories - efficacy

    41. How much change do you want?

    42. Effectiveness + benchmark

    43. PMP survey Grania Fenton Email: ugm6g2f@leeds.ac.uk http://www.survey.leeds.ac.uk/pmpsurvey

    44. Thanks to Chris Eccleston Amanda Williams Johan Vlaeyen Tamar Pincus Lance McCracken Geert Crombez Frank Keefe Shona Yates Fiona Thorne Caitlin Davies Sumerra Hussain Dave Griffiths Ruth Sutherland Sam Harris Ali Fogg

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