10/24/2016

1

Easing the Strain

of Pain on the Brain:

How a New Service Was Developed to

Teach Pain Self-Management Skills for

Brain Injury Survivors, and Useful Take-

Home Principles for Your Practice

Presenters:

Bonnie Cai-Duarte – PT

Bronwen Moore – OT

Co-authors:

Cara Kircher - OT

Sarah Sheffe - OT

We have no conflicts of interest to disclose

Objectives

LEAP

How we redeveloped

Background research

Practice tips

Service model

Evaluation

Objectives 1. Tell you about the LEAP service

2. Review research about pain after brain

injury and the role of self-management

3. Learn about emerging best practice tips

for pain self-management

4. Describe how we redeveloped our

service, and key strategies

5. Discuss client and stakeholder

partnerships in the development process

LEAP

How we redeveloped

Background Research

Practice tips

Service model

Evaluation

LEAP In Brief

• LEAP: Living Engaged and Actively with

Pain

• Open to Toronto Rehab Brain & Spinal Cord

clients with a neurological condition and pain

• Outpatient group programs:

Pain self-management,

mindfulness, and exercise

• Inpatient and outpatient

one-to-one consultations

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2

Why Redevelop?

Redevelopment

needs:

• Changing

organization priorities

• Focus on neurological

population

• Need for update to

services

Former chronic

pain service:

• Any diagnosis

• Outpatient groups

only

• Running 20+ years

LEAP

How we redeveloped

Background Research

Practice tips

Service model

Evaluation

Research Overview:

Pain, ABI, and Self-Management

Pain 101

Pain Basics

Nociceptors pick up changes in temperature, mechanical force, or chemistry

Spinal neurons become excited and send message along spinal cord to brain

Sensory information arriving from the spinal cord is processed in hundreds of areas

Peripheral

nerves

Spinal

cord

Brain

Glutamate

Spinal cord neuron Nociceptor

Pain Pathway Brain

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3

Area Major Function

1 Premotor/motor

cortex

Organize and prepare

movements

2 Cingulate cortex Concentration, focusing

3 Prefrontal cortex Problem solving, memory

4 Amygdala Fear, anxiety, anticipation

5 Sensory cortex “Virtual body”

6 Hypothalamus/

thalamus

Stress response,

autonomic regulation

7 Cerebellum Movement and cognition

8 Hippocampus Memory

PAIN

EXPERIENCE

The Pain Experience is Complex

(Butler & Moseley, 2014)

When Pain Persists, the Nervous

System Can Become Sensitized How Does The Nervous System

Get Sensitized?

Inflammation Chemistry

Spinal cord neurons Brain pathways

Urban, 1999)

(Hass-Cohen & Findley, 2009;

Newton-John & Geddes, 2008;

Neuropathic Pain

• Due to changes to the nervous system:

– Increased excitability of neurons

–Growth and spread of pain-transmitting

neurons into other regions

• The brain may not get a clear signal (or any

signal) from parts of the body

• It can decide that this partial information is

a sign of danger, and interpret it as pain

(Bonin, 2015)

Pain in the “Virtual Body”

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4

Does Pain Always Mean that the

Body is Being Harmed?

Is the Feeling of Pain Always In

Proportion to the Injury?

No!

If You’ve Been Injured, Can Pain

Be Felt in a Totally Different Area?

Yes!

Can Pain Go On, Even Long

After the Body Has Healed? Yes

again!

(Butler &

Moseley, 2014)

Persistent Pain and ABI

Pain is Common After ABI

• Estimates of prevalence of chronic pain

in ABI ranges broadly, e.g. from 43% -

89%

• Synthesis of 20 studies (3289 clients)

shows persistent pain rate of 51.5%

• Seen more often in mild TBI (e.g. 75%)

vs moderate to severe TBI (e.g. 32%)

(Nampiaparampil, 2008)

Common Types of Pain After ABI

Post-traumatic headaches

Neuropathic pain (caused by damage to

neurons in brain or periphery)

Complex regional pain syndrome

(usually affects an arm or leg)

Heterotopic ossification

(Tyler & Lievesley, 2003)

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5

Post-Traumatic Headaches

• Most common sequelae of CHI

• 80% of clients report headache at some

stage of recovery

• After 2 months, rate is 60%

• After 6 months, rate is 44%

• Often seen together with neck pain

(Branca & Lake, 2004)

Why Worry About Pain After ABI?

(Iezzi, Duckworth, Mercer & Vuong, 2007; Martelli, Zasler, Bender & Nicholson, 2004)

• Symptoms of pain and ABI are similar – masking can occur

Misdiagnoses

• Physical

• Functional

• Psychological Impairment

• Anticipation of pain disrupts cognitive efficiency by activating ACC and HPA Axis

Cognition

Risk Factors for Persistent Pain

Thoughts Catastrophizing

Beliefs / Expectations

Low self-efficacy

Feelings Depression

Anxiety, Stress

Anger

Behaviours Fear / avoidance

Sedentary lifestyle

Poor follow-through

Stressors Competing priorities

Lack of social support

Limited physical resources

Risk Factors

(Mann, Lefort & VanDenKerkhot, 2013; Martelli, Zasler, Bender & Nicholson, 2004)

What Helps Persistent Pain?

Best Therapeutic Approaches

CBT Stanos & Houle, 2006

ACT Vowles, Sowden &

Ashworth, 2014

Mindfulness Hassed, 2013

Motivational Interviewing

Miller & Rollnick, 2013

Gentle Exercise

Lee, Crawford & Shoomaker, 2014

Tailoring Interventions

Contemplation “I need to help myself manage

this pain, but I don’t know how!”

Action “I know what helps and what

makes the pain worse.

I have some control.”

Maintenance “I feel I am managing my pain

to the best of my ability.”

Pre-Contemplation “Someone should cure me of this

pain!”

For best results, match intervention to client’s stage of change:

(Prochaska, 1984; Mann, Lefort & VanDenKerkhot, 2013)

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Contemplation

Action

Maintenance

Pre-

Contemplation

Preparation

Raise awareness,

explore benefits of change Address barriers

to change

Monitor, problem-

solve, reward

change

Support,

remind,

trouble-

shoot

Inform,

plan change

Self-Management Education Works!

Self-efficacy

Cognitive coping

Task persistence

Acceptance

Pain (gains can last years)

Catastrophizing, anxiety

Use of analgesics

Healthcare access, ER visits, hospitalizations Pain behaviours

(Hoffman et al., 2007; Mann, LeFort & VanDenKerkhot, 2013;

Nash, Ponto, Townsend, Nelson & Bretz, 2013)

Treatment Goals • Train a variety of coping skills

• Active participation and responsibility

• Relate differently to the pain

Learn

• Pain intensity

• Reliance on pain medication

• Use of healthcare services Decrease

• Physical activity

• Psychosocial functioning

• Engagement in life activities

• Social support

Enhance

(Stanos & Houle, 2006)

Best Pain Coping Skills - ABI

Pacing Stress

management

Sleep hygiene

Managing thoughts

Exercise Task persistence

Assertive-ness

Cultivate acceptance

Relaxation

Managing emotions

(Sommer & Witkiewicz, 2004;

Iezzi, Duckworth, Mercer, & Vuong, 2007; Tyler & Lievesley, 2003)

Relating Differently to Pain

• Encourage task persistence

–Opposite of fear/avoidance pattern

–Linked with better outcomes with pain,

function, mental health and disability (Molton, Jensen, Ehde, Carter, Kraft & Cardenas, 2014)

• Cultivate Acceptance

–Shifting of focus from cure to coping

–Uses active coping strategies

–Predicts adjustment to pain & function

(Stanos & Houle, 2006)

Special ABI Challenges

• People with ABI report less control over

pain than those without ABI (Tyler & Lievesley, 2003)

(Branca & Lake, 2004)

Cognitive impairment

Decreased insight

Mental health comorbidities

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Adapting Pain Treatment for

Clients with ABI

• Provide written & verbal information

• Set up routines, practice and procedural

learning within group

• Involve peers and family

• Plain, clear language and repetition

• Use structured checklists and planning

tools (Sommer & Witkiewicz, 2004)

LEAP

How we redeveloped

Background Research

Practice tips

Service model

Evaluation

Best Practice Tips for Pain

Self-Management Education

Always Ask About Pain

• It’s okay not to have all the answers

• Acknowledge, validate and be curious

• Ask about patterns: “What makes the

pain even a little bit better? What makes

it worse? What do you do when pain

arises?”

• Find out if pain is new or longstanding

Help Clients To Learn About

How Pain Works

• Decreases fear

• Increases

function

(Moseley, Nicholas, & Hodges, 2004)

Good Websites About Pain • www.youtube.com - Videos on YouTube:

– Lorimer Moseley – “Why Things Hurt”

– Hunter Medicare Local – “Understanding Pain: What to do

about it in less than 5 minutes”

• www.cirpd.org

– Articles and videos about pain and the latest research

• www.canadianpaincoalition.ca/

– Articles and videos about pain, research and events

• www.chronicpaincanada.com/

– Lists support groups and education events in Canada

• www.pain.com/

– This site has listings of pain management clinics in Western

Canada, news and message boards

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8

Good Books About Pain

• Managing Pain Before It Manages You.

By M. Caudill (2015)

• The Brain’s Way of Healing by N.

Doidge (2015)

• Explain Pain. By D.Butler & L. Moseley

(2013)

Help Clients Find Ways to

Escape from the Pain

• Distraction

• Social support

• Heat/cold

• Massage

• TENS

• Creams

(Pearson, 2009)

Distraction Works

This brain is

too busy to

process the

pain!

Teach Ways to Calm the Mind

and Body

• Relaxation techniques

• Meditation

• Breathing

• Music

• Sleep strategy education

• Emotional self-management

• Coping thoughts

• Work with catastrophic thoughts

• Willingness vs struggle

(Sommer & Witkiewicz, 2004;

Iezzi, Duckworth, Mercer, & Vuong, 2007; Tyler & Lievesley, 2003)

Relaxation Resources

• Websites – www.guilford.com/MBCT_audio

– health.ucsd.edu/specialties/psych/mindfulness/mbsr/audio.ht

– www.youtube.com

• Jon Kabat-Zinn Meditations

• Cara Kircher (relaxations recorded by LEAP Service)

• Books – The Relaxation & Stress Reduction Workbook By M.

Davis. E.R. Eshelman & M. McKay (2008)

– The Mindful Way Workbook, by J. Teasdale, M.

Williams & Z. Segal (2014)

More Relaxation Resources

• CDs – Letting Go Of Stress: www.drmiller.com

– The Relaxation Experience CD: Meditations for

Optimum Wellness: www.forhealth.ca/order.html

• Apps and Podcasts – Podcasts: Meditation Oasis

(meditationoasis.com/podcast/listen-to-podcast/)

– Cleveland Clinic Stress Free Now App

– Smiling Mind App

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Support Your Client to Challenge the

Pain with Gentle Activity

• Exercise – gentle, novel,

with awareness, build slowly

• Pacing

• Task persistence

• Work with fear/avoidance,

e.g. graded exposure

• Activity adaptation

• Identify highest values, and

invest in those activities

• Assertiveness training (Molton, Jensen, Ehde, Carter, Kraft & Cardenas, 2014;

Sommer & Witkiewicz, 2004; Iezzi, Duckworth, Mercer, & Vuong, 2007; Tyler &

Lievesley, 2003)

Gentle Exercise Resource

• www.youtube.com

–Search: Cara Kircher

–Gentle chair yoga routine (193,000

views and counting!)

–Gentle mat yoga routine

–Coming soon: Gentle tai chi routine

Practice, Practice, Practice!

• Neuroplastic changes

take time (weeks)

• Encourage clients to

stick with strategies

• Approach with low

expectations and lots

of curiosity

• Reward small steps

forward

LEAP

How we redeveloped

Background Research

Practice tips

Service model

Evaluation

LEAP Service

Redevelopment Process

Integrating (March 2015 – June 2015)

Evaluating (June 2015 – Present & Ongoing)

Program/ service creation

Marketing & communication

Set long term goals

Research

Interviews

Logistics

Client and clinician

feedback

Planning (Sept. 2014 – April 2015)

How Did We Do It?

10/24/2016

10

Goodbye / Hello

• Leaving behind the former

service

• Determining and

responding to the needs of

the organization and our

clients

• Reflecting on our strengths

as a team and as

individuals for a fresh start

Planning Okay, Now What?

Brainstorming

Determined

operating

parameters

Met with former

clients

Met with

stakeholders

at all referral

sites

Created a

plan and

timeline

Planning

Needs Assessment

Interviews with clients

Staff surveys

Interviews with staff

Meetings with management

Database review of former service

7 139

8 15

2532 client visits

Planning Research, Research,

Research

• Collected information on program

development and quality improvement

processes

• Conducted a thorough lit review on the

following subjects: fear of movement,

pain catastrophizing, ACT, CBT, self-

management, outcome measurement,

Planning

…and More Research

• Read 40 articles

• Standardized our process for taking

notes on literature according to template

to streamline sharing information among

team members

• Upgraded staff education through

courses in Motivational interviewing, the

ACT matrix, CBT, Depression

management, and hydrotherapy

Planning

Service

Creation Integrating

Travelling Cart with Education

Info

1:1 goal setting

consults during groups Follow up

workshops for

graduates

Provide staff

education workshops

in pain

Adapted pain management

groups

Pool Group/Exercise group leading

into CBT groups

Module Based groups

Offer groups

based on functional

level

Pain management group

Mindfulness group Workshops

1:1 Inpatient consultations

10/24/2016

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Conducting a Phased Roll Out Integrating

Marketing &

Communication

• Attended team business meetings

• Provided staff education sessions

• Due to ongoing evaluation feedback,

increased communication with referral

sources using follow-up emails after

referral, intake / consult)

Integrating

Long Term Goals

1. Research project

2. Publish Manual

3. Share PMG model

Integrating

Changing Your Pain Pathways:

Ways to cope with pain in daily life

LEAP Pain Service – Brain and Spinal Cord Service University Health Network, Toronto Rehab

LEAP

How we redeveloped

Background Research

Practice tips

Service model

Evaluation

Service Evaluation Strategy

& Outcome Measures

Learning How

10/24/2016

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Service Evaluation Strategy

Inpatient

Rating scales for

IP consults

Outpatient

Outcome measures

Client feedback surveys

Group exit

interviews

Focus group

Staff

Online survey

Focus groups

Pain Vigilance and Awareness Questionnaire (PVAQ)

Roland Disabaility Questionnaire (RDQ)

Tampa Scale of Kinesiophobia (TSK)

Illness Behaviour Questionnaire

Cognitive Coping Strategies Inventory (CCSI)

Coping Strategies Questionnaire (CSQ)

K-Scale

Pain Disability Index (PDI)

The Vanderbilt Pain Management Inventory

Brief Pain Inventory (BPI)

Centre for Epidemiological Studies – Depression Scale

Non-communicating Children’s Pain Checklist

Satisfaction with Life Scale (SWLS)

Rand Mental Health Inventory (MHI-5)

SF-36

Chronic Pain Grade

Pain Beliefs and Perceptions Inventory (PBPI)

SOPA – survey of pain attitudes

Multidimensional scale of perceived social support

Multidimensional Pain Readiness to Change Questionnaire

Pain Self-Efficacy Questionnaire (PSEQ

Brief Pain Coping Inventory – 2 (BPCI-2),

Pain Anxiety Symptoms Scale (PASS)

Patient’s Global Impression of Change

Hopsital Anxiety and Depression Scale (HADS)

Utrecht Activities List (UAL)

Life Satisfaction Questionnaire (LiSat -9)

Pain Cognition List (PCL – 2003)

Medical Outcomes Study Short Form Health Survey - 12

Multidimensional Pain Inventory - SCI Version (MPI)

Pain Response Self-statement Scale

Moorong Self-Efficacy Scale (MSES

Ways of coping inventory

Outcome Measures Pain Vigilance and Awareness Questionnaire (PVAQ)

Tampa Scale of Kinesiophobia (TSK)

Cognitive Coping Strategies Inventory (CCSI)

Coping Strategies Questionnaire (CSQ)

K-Scale

Pain Disability Index (PDI)

The Vanderbilt Pain Management Inventory

Brief Pain Inventory (BPI)

Satisfaction with Life Scale (SWLS)

SF-36 and Study Short Form Health Survey – SF 12

Pain Beliefs and Perceptions Inventory (PBPI)

SOPA – survey of pain attitudes

Multidimensional Pain Readiness to Change Questionnaire

Pain Self-Efficacy Questionnaire (PSEQ)

Brief Pain Coping Inventory – 2 (BPCI-2)

Patient’s Global Impression of Change

Life Satisfaction Questionnaire (LiSat -9)

Pain Cognition List (PCL – 2003)

Multidimensional Pain Inventory - SCI Version (MPI)

Moorong Self-Efficacy Scale (MSES)

Ways of coping inventory

32!

21!

Chosen Measures - PMG First outcome measures package

Pain Catastrophizing Scale (PCS)

Chronic Pain Acceptance

Questionnaire (CPAQ)

Canadian Occupational Performance

Measure (COPM)

Numeric Pain Rating Scale (NPRS)

Chronic Pain Coping skills Inventory

(CPCI - 42)

Physical activity level / stage of

change

Second version

of package

PCS

CPAQ

COPM

Third version of

package

PCS

CPAQ

COPM

NPRS

SF – 36 (QoL)

Chosen Measures - MMG

• Considered 5 questionnaires

• Based on length, readability, and

psychometrics we chose:

the Mindful Attention

Awareness Scale

(MAAS)

(and the

CPAQ)

What We Found So Far

Good!

Bad

Outcome Measures

Measure 1 Measure 3 Measure 2

Legend:

Before PMG

After PMG

Shhh! Evaluating the Inpatient Consults

• Limits of the consults:

–1 hour

–Not resourced for ongoing follow up

–Brief assessment and education

• Meaning: We were unable to use

formal outcome measures

• Instead: we developed rating scales

based on the COPM scales

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4.3 4.4

7.2

8.7 8.5

0

1

2

3

4

5

6

7

8

9

10

Goal knowledge Goal confidence How well we metexpectations

Inpatient Knowledge, Confidence And Satisfaction Ratings (n=41)

Pre-consult Post-consult

Staff Online Survey &

Focus Group

• Surveyed 51 staff about the service 6

months into the roll-out

• Conducted two focus groups with staff

who were eligible to refer clients to

LEAP

What We Found So Far Top 3 reasons why staff

refer clients to LEAP: Online Survey

• To engage clients in self-management (86%)

• To get information about pain management (86%)

• To work towards pain-related goals (86%)

Focus

Groups

• Mood and pain are the biggest therapy barriers

• Prevention: referring clients before pain becomes chronic

• Strategies generalize beyond pain coping

• Validation and normalization of pain experiences

“Pain and mental health issues are

common. If someone is walking around in

pain and so focused on that, they can’t

function well in work, school and

relationships.

The strategies you teach are not

necessarily specifically for pain. It may

transfer over to sleep, anxiety, and

depression. I think it’s hugely beneficial.”

- Referring clinician

What We Changed

More ongoing

communication back to

referral source

Outpatient consult option

Exercise groups

(hydrotherapy and chair

yoga/tai chi)

Client Feedback Surveys, Exit

Interviews & Focus Group

• Surveyed 40 clients who attended a

LEAP group

• Conducted a focus group with 4 clients

who had attended LEAP groups

• Conducted exit interviews with all clients

who attended a LEAP group

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0

1

2

3

4

5

Pain Management Group Feedback (n=40)

5 = Excellent 4 = Good 3 = Satisfactory 2 = Poor 1 = Very poor

Feedback Themes Group

interactions: Group discussions and

sharing were very important to the learning experience,

even when difficult.

Quality: The group was helpful and

appreciated.

Strategies & perspective:

Clients have made concrete lifestyle changes, and

changed their perspectives on pain.

Barriers to learning:

There are barriers to learning – visual, hearing, cognitive,

language & pain.

Length of group / timing:

The group should be longer (more time for discussion,

relaxation and movement), if clients could tolerate it.

Manual: The manual was helpful,

though some found it a bit lengthy.

Breathing and relaxation:

Breathing and relaxation techniques were valuable.

Exercise: Movement breaks were

generally appreciated; but one client found them

distracting.

Logistics: The group is well organized.

“This course clears the clouds. It opens

the opportunity for change. It made a

bridge for me to cross in my life.”

- LEAP Client

In Their Words In Their Words

“I realized that my life could go on,

despite the pain. I learned that it was not

all “outside my control”. I learned that I

had the power to change the way I

thought about pain and reacted to pain.

…Although I can’t always make the pain

go away, there are things I can do to

make it better, to make it easier for

myself.”

- LEAP Client

What we changed

Altered group session layout

to add more time for exercise

and discussion

Optional community resource

session

Currently creating additional

peer support session

Constant Upgrading Collect, Analyze, Upgrade

January February March April

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10/24/2016

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Are You Redeveloping?

Here Is Our Advice

Advice and Strategies for

Those Facing Redevelopment

Building the New Service

• Ask a lot of questions up front from

those driving the change

• Be open to many possibilities

• Use lots of types of evidence

• Take the strengths from your old service

• Roll out gradually

Evaluation

• Be ready to show progress at any time

• Evaluate everything

• Let go of things that aren’t working

• Build in time for processing service

evaluation data & cycling in changes

• Get lots of stakeholder input

Growing

• Expect a period of uncertainty

(for us: ~ 1 to 1.5 years)

• Stay flexible (don’t share plans too

soon!)

• Set many short-term goals with clear

leaders and deadlines

• Communicate often about priorities

• Keep the long-term vision in mind

Marketing & Communication

• Market early and often

• Be clear about “what’s in it for them”

• Be clear about what you don’t do

• Report back to referral sources often

• Build bridges (but keep your own goals

front and centre)

• Make referral easy

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Take Care of Yourself

• Take slow, deep breaths

• Find something to get excited about

• Invest in your team

• Be open to new ideas

• Be realistic about time

• Play to your strengths

New Service Model:

LEAP Current State

LEAP

How we redeveloped

Background Research

Practice tips

Service model

Evaluation

Operating Parameters

• Resources:

–2.4 FTE staff (1.8 OT, 0.6 PT)

• Serving:

–3 sites: University, Lyndhurst and

Rumsey Centres

–5 populations: SCI, ABI, MS, Stroke, CP

– Inpatient and Outpatient

Who Can Refer?

• All clinicians, nurses and physicians

• Toronto Rehab Brain and Spinal Cord

program only (no external referrals)

Eligibility

• Patient in TRI Brain and Spinal Cord

program

• Have a neurological diagnosis and pain

• Open to self-management approach

• Able to communicate (at least yes/no)

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Eligibility for Groups

• Appropriate cognition & behaviour

• Sufficient English proficiency to follow

discussion

• Manage transportation and toileting

while on site

• Not intended for management of crises

Inpatient Services: Focused

Consults

• Topics:

• Pain education

• Stress management

• Family education

• Pain Resources

• Relaxation

Outpatient Services Provided

• Pain Management Groups

• Mindfulness Meditation Groups

• Exercise groups

–Hydrotherapy

–Chair yoga and tai-chi

• Individual education sessions

• Group follow-up (refresher workshops)

Pain Management Group

• 9 weeks, 1 x / week, 2 hours, 8-15

members

• Each class: 30 minute relaxation, 1.5

hour content, adapted movement break

• $30 Materials cost requested

Pain Management Group Outline

1. Understanding pain

2. Doing what matters

3. Stress, relaxation and breathing

4. Exercise & Movement

5. Sleep

6. Thoughts about pain

7. Dealing with moods

8. Communication

9. Re-cap & flare-up plan

Mindfulness Meditation Group

• 9 weeks, 1 x / week, 2.5 hours, 8-15

members

• Focus on mindfulness practice and

discussion

• Based on “The Mindful Way Workbook”

• $30 Materials cost requested (but book

available for free at Public Library)

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Exercise Groups

• Hydrotherapy

• Chair yoga and tai-chi

–4 to 6 weeks long

–Designed to teach a program clients

can do independently at community

pool/home

Example Of Patient Care

Pathway

Step 1: Inpatient Consult

Step 2: Outpatient

intake

Step 3: Pain Mgt

Group

Step 4: Exercise Group

Step 5: Mindfulness Meditation

Group

Step 6: Refresher

Work-shops

Questions?

Our Contact Info:

LEAP @uhn.ca

(416) 597-3422 ext. 5298

Thank you for your time!

References

Branca, B., & Lake, A. E. (2004). Psychological & neurological integration in

multidisciplinary pain management after TBI. Journal of Head Trauma

Rehabilitation, 19, 40-57.

Bonin, R. (2015). Running from pain: mechanisms of exercise-mediated

prevention of neuropathic pain. Pain,156(9), 1585–1586,

http://dx.doi.org/10.1097/j.pain.0000000000000302.

Butler, D., Moseley, G. L. (2014). Explain pain (2nd Ed.). Australia: Noigroup

Publications.

Hass-Cohen, N., Clyde Fidnlay, J. (2009). Pain, attachment, and meaning

making: Report on an art therapy relational neuroscience assessment protocol.

The arts in Psychotherapy, 36: 175-184.

Hassed, C. (2013). Mind-body therapies use in chronic pain management.

Australian Family Physician, 42(3), 112-117.

10/24/2016

19

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