Mark Johnson Presents Psychological Perspectives and Outcomes for CRPS

Mark Johnson Presenting at RSDSA Conference
Mark Johnson Presenting At RSDSA Conference for Complex Regional Pain Syndrome

Mark Johnson has a Ph.D in Clinical Health Psychology and Behavioral Medicine from the University of North Texas, and completed medical psychology rotations at Duke University Medical Center. His specialties include chronic pain, sleep, and co-occurring mood disorders. Dr. Johnson has been with the Bay Area Pain and Wellness Center since 2014.

This presentation is part of a broader discussion on integrated Solutions to CRPS, treating the whole person, and optimizing wellness.

Transcript

 

00:12
our next speaker is dr. Mark Johnson he
00:15
has a PhD in clinical health psychology
00:17
in behavioral medicine from the
00:19
University of North Texas and completed
00:22
medical psychology rotations at Duke
00:25
Medical Center his specialties include
00:27
chronic pain sleep and co-occurring mood
00:31
disorders sounds like he's in the same
00:33
good room huh
00:34
and dr. Johnson has been with the bay
00:37
area pain and wellness center since 2014
00:40
dr. Johnson it's an honor to be at the
00:44
tail end of such heavy hitters here
00:46
today they're a hard act to follow
00:49
there's been a number of things that I'd
00:51
like to touch upon that each have said
00:54
and I hope that you're gonna hear some
00:59
overlap in what I have to say because
01:02
that's a big part of what we do there's
01:05
a distinction between an
01:07
interdisciplinary program and a
01:08
multidisciplinary Multan
01:10
multidisciplinary can have multiple
01:13
components but not necessarily
01:15
dialoguing with each other not
01:17
necessarily a team effort and the type
01:22
of work that we do as an
01:23
interdisciplinary program we do have a
01:25
lot of overlap a lot of repetition I'm a
01:28
lot of team work and a lot of everybody
01:31
focusing on patients together so to
01:37
segue a little bit off of some of what
01:39
dr. Massey said there's in a review of
01:45
evidence-based literature there's been
01:47
questions that have been asked as far as
01:49
do individuals with CRPS have
01:52
psychological differences compared to
01:55
other pain populations again that whole
01:58
idea of if this is so out of proportion
02:01
and there's not really a medical
02:03
explanation for it you know is there
02:07
something different going on with these
02:08
individuals there's no evidence of that
02:11
and there's also been questions as far
02:14
as was there some type of pre-existing
02:18
condition was there some significant
02:20
some anxiety or depression or other
02:22
conditions going on prior to the canoe
02:26
and once again there's no evidence of
02:28
that so what we do know is that patients
02:33
with chronic pain tend to be more likely
02:36
than the general population to develop
02:40
psychologic to psychological disorders
02:42
and so as others have been saying if
02:45
you're dealing with intense chronic pain
02:47
on a daily basis and it's disrupting you
02:50
know every aspect of your life there's
02:52
going to be a high level of probability
02:56
that's that's gonna lead to more worry
02:58
and more anxiety more depression and so
03:00
forth anxiety and depression are
03:03
positive predictors of pain as well as
03:06
the number of medications a person takes
03:08
as well as their perceived level of
03:11
disability depression can do a whole
03:15
bunch of things that can impede recall
03:18
of changes in pain levels and alter a
03:20
person's perception of pain experiencing
03:25
a day of depression can predict a
03:27
following they have increased pain and
03:30
these are just some of the big ones but
03:33
other things get affected too there's
03:36
been some research that individuals with
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CRPS it may also affect their ability to
03:42
empathize with others which makes sense
03:44
if you have a body part that's
03:46
constantly screaming at you it may be
03:48
harder to sort of feel what you need to
03:51
feel for some of the other significant
03:53
people in your life so there are these
03:54
social disruptions it's been suggested
03:59
that people with CRPS and do pretty well
04:02
initially there's a minimal
04:03
psychological response but over time
04:06
over the course of six or eight weeks
04:09
more things start to take their toll and
04:11
then it is recommended that there's some
04:13
psychological assessment to go with that
04:16
this is just a quick model that's very
04:20
relevant in the physical therapy
04:23
components of our program which is the
04:25
the person who's injured and
04:27
experiencing pain often may go into
04:30
those catastrophizing thoughts which can
04:33
lead to a lot of pain relief pain
04:36
related fear activity avoid
04:38
further disuse further disability
04:40
further depression which just keeps
04:42
cycling inward and so a big part of the
04:45
way that we treat pain is to try to
04:47
confront that and see if we can get
04:49
people to be able to move and be active
04:52
despite the fact that they have pain and
04:55
may be learning that the consequences
04:56
aren't as bad as they think and and
05:01
probably when we do have people which
05:03
occasionally happens people that leave
05:06
the program very early after just a few
05:08
days it's usually because their pain
05:10
does increase there's a lot of fear
05:12
around that there's the idea of this is
05:14
making me worse and then people
05:17
sometimes bolt based on that so when it
05:25
comes to the psychological eyes
05:26
psychological aspects of this it's
05:28
looked at more as an interaction rather
05:31
than a cause-and-effect and the idea is
05:34
that the person who's having
05:37
psychological distress whether it's pain
05:39
related or whether it's non pain related
05:42
it can involve it can involve
05:44
maladaptive cognition such as
05:46
catastrophizing and thinking the worst
05:47
case scenarios it can also involve
05:50
dysphoric emotions such as anxiety and
05:53
depression that is thought to feed into
05:56
some pathophysiological mechanisms so
05:59
initially a stress response in the body
06:01
based on acute stress is a good thing
06:04
it's gonna have some anti-inflammatory
06:08
effects but when there's a prolonged
06:10
stress response you start to see some
06:13
cortisol dysfunction you start to see
06:16
increased inflammation as well as
06:18
formation of fear-based memories and all
06:21
of that can initiate exacerbate or even
06:24
prolong the pain experience as well as
06:26
lead to things like central
06:28
sensitization so these are kind of
06:30
proposed models of what might be going
06:33
on for the person who is experiencing a
06:37
more and more persistent situation there
06:43
is some evidence that life events might
06:46
proceed CRPS this would basically be
06:49
negative life events
06:51
and the idea is kind of what I was just
06:55
talking about based on a repeatedly
06:58
triggered sympathetic system it could
07:00
create prolonged increased autonomic
07:03
arousal and again you start seeing those
07:05
results that we were just talking about
07:08
so research indicates that children with
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CRPS report more negative life events as
07:15
well as more family related life events
07:20
there's also been some very recent
07:24
research I think this was a 2017 article
07:27
that just came out very recently of a
07:29
hundred and fifty two patients with CRPS
07:32
58 of them or 38% had had life events
07:38
prior to the to the CRPS onset that had
07:41
PTSD associated with it I've also heard
07:44
numbers that as up to as high as 90
07:48
percent of individuals but again most of
07:52
the evidence-based research I've been
07:54
reading is suggesting that we're still
07:56
in the some evidence range of this and
07:58
there's also tends to be a higher
08:01
incidence of females again different
08:04
literature will suggest there's a three
08:06
to one ratio 4 to 1 ratio 5 to 1 ratio
08:09
but it does seem that this is afflicting
08:12
females more than men and there's also
08:17
some evidence of hereditary influence
08:19
that correlates with an earlier onset
08:21
when you see younger individuals
08:24
develops you see RPS there tends to be
08:26
some other family members that have been
08:29
dealing with that as well some other
08:31
things I wanted to touch upon is just
08:33
some of the assessment and treatment
08:35
issues and then after that I want to
08:38
follow up talking about the outcomes
08:40
that our clinic gets so in terms of
08:42
psychological assessment we do like to
08:45
try and then identify any significant
08:47
ongoing stressors that individuals may
08:50
be having we look at early life
08:53
stressors we look at stress at the time
08:54
of injury we look at stress since the
08:56
injury we're basically looking for those
08:59
factors that could cause that heightened
09:02
sympathetic response that overactive
09:06
sympathetic activation for individuals
09:09
that could be again maintaining or
09:11
exacerbating we try to identify any
09:14
co-occurring conditions such as
09:16
depression anxiety panic PTSD if those
09:21
are present we try to target them
09:23
specifically and we we do that in a
09:26
variety of ways sometimes people want to
09:29
address those things while they're in
09:30
our program sometimes people kind of
09:33
want to hold off on weight and so we do
09:35
have people that complete the six weeks
09:37
of our program and then come back and
09:40
continue with individual psychology
09:43
follow-ups we're looking in general also
09:47
at cognitive emotional and behavioral
09:49
responses adaptive versus maladaptive
09:52
types of coping and even the responses
09:57
of significant others I was really glad
10:00
to hear dr. Mackay talk about the power
10:03
of love and sometimes that's a potent
10:07
factor that comes up for people
10:09
throughout the course of treatment is at
10:10
a certain point they say hey you know
10:12
what I'm kind of realizing that in
10:14
addition to everything else I want to
10:15
work on my marriage or something that's
10:18
really at the core of their life you
10:21
know I've seen a few people at the end
10:23
of the program short while later end up
10:26
going through divorces other people
10:28
sometimes want to bring in their family
10:30
members and that's always welcome in our
10:32
clinic too if people are trying to work
10:34
those things out in terms of
10:37
interventions I tried to kind of
10:39
separate two categories here one I see
10:44
the role of psychology in our clinic as
10:47
highly supportive to the other
10:50
components of the program so some some
10:52
of the things that we're trying to
10:53
address is that hurt versus harm a big
10:57
cornerstone of our program is just
10:59
education and we like to sometimes say
11:02
tissue is not the issue and you know
11:06
look at the fact that an individual may
11:11
have that fear that this hurt so I'm not
11:14
going to do it
11:15
when that fear of movement again can
11:19
lead to disuse avoidance that can lead
11:21
to a host of complications and a
11:25
worsening of the condition so we do
11:29
support those exposure techniques as
11:31
well as a lot of relaxation based
11:33
techniques in addition we do really
11:37
focus a lot on relaxation training to
11:39
increase a sense of control over a
11:41
person's pain as well as decrease
11:44
emotional arousal we target some of the
11:47
maladaptive thoughts that could be fear
11:49
invoking for individuals again we'll
11:53
focus specifically on any mood related
11:56
issues that come up
11:59
definitely including sleep that was
12:02
mentioned and that's always a big one
12:03
for people and will address any family
12:08
issues that may come up and just teach
12:10
general pain coping skills in general so
12:12
it's a very holistic kind of approach
12:15
which really has to make sense because
12:17
there's only so much you can do to a
12:20
body part and if somebody has you know
12:24
been taking medications injections
12:25
surgeries again a body part can only
12:29
take so much and if you've got a lot of
12:31
other factors that are contributing to
12:32
the condition it really makes sense to
12:34
address all of them and theoretically it
12:37
should have a palliative effect for
12:39
individuals there was a interesting
12:43
research piece that came out which was
12:45
based on advice from CRPS patients to
12:50
CRPS patients people who had gone
12:52
through some good improvement and all of
12:55
their input was categorized into the
12:57
main theme of playing an active role in
12:59
regaining control again that's a big
13:02
part of what we're trying to do is get
13:04
people to move away from passive
13:06
modalities passive therapies and go more
13:08
into self management and active control
13:11
of their condition some sub-themes were
13:13
acceptance and the idea of acceptance is
13:17
it's not something that has an endpoint
13:19
to it but it's sort of something that
13:21
people continue to grapple with and kind
13:23
of move in and out of
13:25
gaining the right support meaning the
13:29
people who the people in your life who
13:31
are trying to support and help you are
13:32
actually supporting and helping you not
13:34
working against you in any way and
13:37
becoming informed just getting the
13:40
information and the education I think
13:42
there's been a lot of that here today
13:44
interdisciplinary pain management is
13:47
recommended for CRPS people who complete
13:50
it shall increase positivity feelings of
13:53
being understood feeling validated
13:56
perceiving that they're starting to take
13:58
back some control over their lives which
13:59
is really important and significance and
14:05
significant improvements have been shown
14:08
in these areas I just want to say that
14:11
this is based on pretty scant literature
14:14
there's not a lot of information and one
14:16
of the first studies I think that was
14:18
maybe around 2004 it was based on 12
14:21
people in the program and so we usually
14:24
see pretty small numbers and there's
14:26
only a few but they do show improvements
14:28
in physical functioning and perceived
14:30
disability better adaptive coping more
14:34
pain acceptance less emotional distress
14:36
reduced meds of note pain intensity
14:40
often does not reduce to a great deal
14:45
however people that go through our
14:48
program often will say my my pain is
14:52
about the same but I'm more flexible I'm
14:54
stronger I'm doing more doing a lot of
14:56
things I didn't think I could do I'm
14:58
functioning better my mood is better my
14:59
sleep is better and so it tends to be a
15:02
win people are kind of like so many
15:03
other things change I'm not even worried
15:05
about this as much anymore so I'd like
15:08
to just share the results we've been
15:10
getting now and I thought the most
15:11
interesting way of doing this would be
15:13
to compare to what we're usually seeing
15:16
in the general population we serve which
15:18
tends to be just all all different body
15:24
parts multiple injuries we we don't
15:26
really cherry-pick into any specific
15:29
thing we're treating a lot of things and
15:32
when it comes to kinesio phobia or the
15:37
fear of movement
15:39
we tend to see with individuals with
15:43
CRPS about an 11% reduction meaning
15:48
improvement and compared to our our
15:52
general pain population it's about the
15:54
same in terms of activities of daily
15:56
living the direction of coming down
16:01
means less and less still a less
16:04
disability for individuals so this is a
16:06
good direction this means better
16:08
functioning and activities of daily
16:10
living our general population improves
16:14
by about 16% individuals with CRPS again
16:18
are around 11 so a little bit less
16:21
improvement in terms of this category in
16:24
terms of pain intensity this was what I
16:28
was saying we only see a very a very
16:32
small level of improvement in pain
16:34
intensity but in terms of pain
16:36
interference this was probably one of
16:42
our largest effects which is 25 close to
16:46
25 percent decrease in pain interference
16:48
so again the pain is interfering a lot
16:51
less and that's even better than it is
16:52
for our general pain population at 22%
16:57
we see improvements in depression and
17:02
anxiety that are very comparable to what
17:04
we see with others that we treat 27
17:07
percent improvement for depression 30
17:10
percent for anxiety what that actually
17:12
means is if somebody comes into the
17:14
program saying they're moderately
17:16
depressed they might finish saying they
17:19
might finish being in the mild category
17:21
so it's kind of a full jump same thing
17:24
with anxiety it could go from moderate
17:26
level to mild or severe to moderate in
17:30
terms of coping this is our measurement
17:33
of either illness focused coping of kind
17:37
of guarding resting protecting the area
17:39
versus wellness focused which is more
17:42
active pain management and our two
17:47
largest effect sizes are
17:49
again the same pretty close to the same
17:53
for general actually even a little bit
17:55
better for individuals with CRPS which
17:57
is a lot more use of exercise and
17:59
relaxation to cope with their pain and
18:04
one more thing I wanted to mention is
18:08
what dr. Bochy started with this morning
18:11
was that really the big goal is can
18:15
people be happy while being challenged
18:18
with CRPS and I think that's what we
18:21
often see coming out of our program is
18:23
is people saying this transformed me I
18:26
kind of got my life back
18:28
a lot of things changed you know the
18:31
pain is still there but despite the pain
18:32
people are getting back to feeling like
18:34
they've got a good life they're more in
18:37
control they're doing better
18:38
self-management and it's dr. Massey was
18:41
saying our goal is to get people out of
18:44
the medical offices you know getting
18:47
your lives back living the best quality
18:48
of life you can and not having to rely
18:50
as much on patients would