Overcoming Chronic Pain Frances Cole

Overcoming Chronic Pain Frances Cole

Contents

Foreword            2

Introduction       2

Chapter 1 Understanding the impact of pain and making changes             2

Person centred model   2

Chapter 2 Understanding chronic pain and pain systems                3

Theories of pain               4

Chapter 3 Understanding investigations for pain               5

X-rays and CT scans         5

MRI Scans           5

Bone scans         5

Chapter 4 Understanding the roles of healthcare professionals  5

Chapter 5 Understanding the medicines and using them better 6

Chapter 5.5 Overcoming chronic pain introduction            7

Chapter 6 Setting goals  8

Chapter 7 Giving yourself rewards           8

Chapter 8 Understand pacing skills           8

Chapter 9 Getting fitter and being more active   9

Chapter 10 Problem solving         10

Chapter 11 Understanding sleep and sleep problems      10

Pain and sleep   11

Changing unhelpful sleep routines           11

Chapter 12 Relaxation    11

Chapter 13 Pain communication and relationships            11

Chapter 14 Managing, depression, anxiety and anger     12

Chapter 15 Acceptance 15

Chapter 16 Maintaining progress and managing setbacks              16

Chapter 17 Looking to the future and Managing work     17

Foreword

People try to avoid pain, but chronic pain sufferers can’t. So we seek to improve pain management to reduce suffering and we do this by firstly understanding pain generally then your pain, and its patterns. So we aim to move from a pain sufferer to a pain manager.

You need groups of skills to be an effective pain manager.

Introduction

There are usually several reasons why people have chronic pain.

10% of adults have pain in their body at any one time. Pain can affect the way you think, feel, and behave.

Chronic pain, means pain that has lasted for over 3 months.  The nerves carrying pain message can have developed a memory of transmitting the pain message which is hard to change. Sometimes the reasons for pain are not discovered even after extensive tests.

If there is no known cause for a person’s pain, then this can lead to worry anxiety and depression.

Chapter 1 Understanding the impact of pain and making changes

Rate how far pain is controlling you.

Person centred model

Body symptoms

Moods

Thoughts

Behaviours

Situations past and present

Use this to see the effects, i.e. the thoughts, emotions, about pain. How pain affects behaviour and life situations, and what the pain symptoms are

Out of the effects, create a problem list that can be targets to change, select 3 things you would most like to change. Choose the things that affect you every day, what would you like to change, what would be different if you managed your pain deter.

If you reach your target what would this effect.

Write down advantages of changing and the advantages and disadvantages of changing.

Then write down your main reason for wanting change and your main concern about it.

Think about how you are now and what you can and do manage, then write down 3 strengths, and three things that keep you going.

Then write down how important the change is you are going to make, how confident and how ready you are to change now.

You must focus on what can be changed and what is under your control.

Chapter 2 Understanding chronic pain and pain systems

Difficult to describe pain so difficult to communicate to someone else how it makes you feel, so they can’t empathise, you can feel alone. Pain description words: aching, shooting, stabbing, sharp, nagging.

Describing pain:

1.       Its sensation

2.       Its effect

3.       What you think of it

a.       Its reason

b.      The future

c.       How it affects you in the present

Nearly all injured tissues are fully healed in six months

Most pain symptoms reduce within 6 weeks

Chronic pain that lasts more than three months is not normally associated with damaged tissues,

It can persist as the nerves carrying pain signals develop a memory, a habit for sending the signal.

Pain puzzles

1.       Injured athletes ore soldiers don’t feel pain when they are injured  doing their activity

2.       People can feel pain in phantom limbs

3.       Person who thinks they have a nail through their foot is in great pain but it’s actually gone through their boot

Therefore pain is not just a physical think but is also constructed out of the meaning of an event.

Purpose of acute pain: fast behavioural system to stop the human being injured. Acute pain is transmitted on the A nerve fibres, which are fast

Chronic pain is transmitted on the C nerve fibres which are slow. They can continue transmitting many months after tissue damage is healed, like a traffic light that gets stuck on. Their nerve endings can become very sensitive to movement, changes in temperature and chemical changes.  They then send of many pain signals which seems to magnify pain and cause other sensations like numbness or tingling.

Feeling chronic pain does not mean that there is tissue damage, it could be a faulty message.

Scar tissue from healed tissue can become tight and stiff and there can be pain nerves in there, so that when moving this part of the body, the lack of flexibility can cause pain messages.

Drugs can make the symptoms of pain easier but don’t address the cause, they don’t know how to shut off the C nerve signals.

Acute pain means you should reduce activity for 2 or 3 days especially in there is swelling, but then start to do more.

Resting in bed and cutting down all activities is never recommended as an approach to pain, rather pottering at own pace, cutting down some activities if pain is bad is recommended.

Theories of pain

Gate control theory: there are gates in the nerve conduit in the brain, they open to let messages through to the pain system. They can also close to stop messages getting through.  The body can produce chemicals to close the gate, e.g. endorphins. #there are no treatments that can shut the gate all the time.

What opens and closes your gate?

In injury muscles become tight to protect an area to help the healing process. When the healing process is complete the muscles may still be tight as you are worried about the area. This can lead to constriction on nerve fibres meaning that they get inflamed and that any movement of the tight area can press on them and then create nerve signals.

The vicious cycle

Muscles and tissues are tight 

Any movement to area can produce pain

Muscles and tissues tighten to protect the pain area

Pain cannot be measured like insulin by doctors, so it is invisible. MRI scans can show the brain activity is different when people are in pain, but it seems everyone’s pain is different.

Chapter 3 Understanding investigations for pain

Blood tests there are no blood tests that can tell us the exact cause of chronic pain. There is one exception to this which is ankylosing spondylitis.

X-rays and CT scans

Whenever an investigation is performed ask what is being checked for and what do positive and negative findings mean

X-rays tell us about bones and joints.  Congenital means from birth.

X-rays aren’t useful for chronic pain, they are more use with acute pain.

All these have radiation so shouldn’t be done too often

MRI Scans

MRIs show skin, bones and soft tissue (nerves, muscles, joints cartilage etc.)

No radiation in MRI scans

If you get a negative result from an MRI scan then it’s telling you the structures it scanned are normal so you can gradually increase physical activity.

Chronic pain does not mean you will harm or damage the pain areas through increasing physical exercise.

Bone scans

Dexa, a bone densitometry, will find out how dense your bones are and whether you risk osteoporosis.

An isotope bone scan checks or inflammation

Keep your body active a lack of fitness can make pain symptoms worse, things get stiff, muscles lose ability and then when used become overused and painful

When you wait for pain results then you focus on pain, and it can increase your pain, both directly through symptom and indirectly for the meaning you put on the prognosis, which provides stress and depression.

Chapter 4 Understanding the roles of healthcare professionals

Tens machines change the way pain signals are sent to the brain, so they close the pain gate.

A pain specialist is normally a doctor who has trained as an anaesthetist and has developed additional skills in pain relief. They can prescribe pharmaceuticals.

Psychiatrists medically trained doctors specialising in mental health

Chapter 5 Understanding the medicines and using them better

What medication are you taking?

Has it helped?

What are the side effects?

Have you ever tried to cope without them?

4 types of medicines used to manage pain

1.       Analgesics

a.       Painkillers: codeine, morphine, tramadol, paracetamol etc.

b.      Body makes its own analgesics, which are opioid like: endorphins

c.       Opioids mimic endorphins and attach to the opioid receptors in the brain and spinal cord and reduce pain signals in the pain systems.  The pain “killers” reduce pain, but do not eliminate it

d.      Side-effects=constipation, feeling sick, itching, loss of concentration, sleep problems, depression

2.       Anti-inflammatories

a.       Releases chemicals in affected area, to reduce swelling: ibuprofen, diclofenac

b.      Side effects=skin rashes, indigestion, bleeding from stomach

3.       Anti-depressants

a.       Tri cyclic, e.g. amitriptyline, can help reduce chronic pain and sleep problems, in small doses.

b.      Side effects drowsiness, poor concentration

4.       Anti-convulsants

a.       e.g. gabapentin, or carbamazepine, used to treat epilepsy and can reduce pain coming from the nerve fibres, called neuropathic pain and can help after shingles

b.      Side effects drowsiness, balance difficulties, dizziness

c.       Current medical opinion says tranquillizers such as diazepam (Valium) and lorazepam (Ativan) have no use in acute back pain management. Can cause dependence

WHO recommends

Mild pain, i.e. less than 4/10 paracetamol & diclofenac

Moderate pain 4-7/10 weak opioid drugs, i.e. co-codamol, tramadol

Severed pain 7-10 strong opioid drugs, e.g. morphine, oxycodone

Analgesics work well for acute pain, but don’t seem helpful for chronic pain as it works differently.

Some of the problems in chronic pain, is because the pain system is on high alert you may get it going off when it doesn’t need to, i.e. false alarms.

Sometimes pain nerves that take pain signals to and from the brain to the pain site are faulty, like all the traffic lights being on

When there are a lot of pain signals coming in the brain can get confused and can think there is a pain alert needed for a part of the body that isn’t sending signals.

Withdrawal symptoms from analgesics can be shaking, itching, feeling sick

Drugs as much as they have an effect on the human body, also have effects on other drugs, this is called drug interaction

Ways to manage chronic pain=stretching, exercising, relaxation techniques, pleasurable activities, distraction techniques

Note how severe the pain is before you take medication. Waiting until it is 7-10 is probably not useful as it’s very hard to bring down, we call this the wait and see trap

It can be helpful to take analgesics at regular times

What do you do if you take analgesic and the pain level is still too high?

1.       Take more

2.       Take tablets earlier next time

3.       Try something else to reduce pain, e.g. relaxation

Breakthrough pain, is the pain you can feel before medication, on a regular analgesic ingestion timetable.

To stop medication then establish advantages and disadvantages of taking it.

If you want to stop medication then you have the following options

1.       Reduce by a tablet every 2 to 3 days

a.       Do this for one tablet type at a time

Chapter 5.5 Overcoming chronic pain introduction

Chronic pain can be very difficult as it does not respond well to medical treatments and it affects a person’s relationships

Pain cycle

Persistent Pain=>

Less active=>

Loss of fitness, weak muscles and joint tissue=>

Lack of energy and tiredness=>

Stress\anxiety\anger=>

Negative thinking about the future=>

Depression=>

Time off work, money worries, relationship concerns

Chapter 6 Setting goals

What goal can you have even though you have chronic pain? When you don’t have pain, you set goals informally, when you have pain, it can be helpful to be more formal about this.

Set SMART goals and set a goal ladder, on how to achieve your goal, i.e. shaped little steps.

Goal ladder=

Week

Activities to help me achieve my goal

Things that helped my progress

Things that blocked my progress

Fill out progress every week.  Reward for success but save the biggest reward until last

Chapter 7 Giving yourself rewards

A reward is something that gives you a sense of pleasure or a sense of achievement.  They help us to repeat activities. People tend to avoid situations with unpleasant outcomes, e.g. being shouted at, told off or rejected. Rewards motivate punishment demotivates. Some people who compare themselves with how they used to be don’t think they should reward themselves.

Make a list of pleasurable rewards and sense of achievement list, these can be used to motivate yourself.  Then write a fun prescription.  Having fun releases endorphins which can reduce pain, and at the very least it can be a distraction

Chapter 8 Understand pacing skills

Pacing means reaching a balanced pattern of varied activity at a steady pace using time or distance not pain as a guide. This also means not overdoing on better days or underdoing on worse days. Pacing means doing some activities even at times when you don’t feel like it.  

People can vary what they do because of pain. This is useful for acute pain, but with chronic pain this means pain control you.

Pacing is a skill that takes some practice.

Different styles of pacing:

Unhelpful styles

1.       Overactive

a.       Doing too much: which results in straining your body, which means you stop, then your body becomes stiffer and not so strong

2.       Underactive

a.       Doing too little: not stretching your body, not making it strong again, which means they tire more easily

Helpful pacing style

1.       Focus on doing important activities at a steady pace with regular breaks

2.       Reduce high standards when in high pain

3.       Plan activities that are realistic.

Do advantages and disadvantages of your coping style. If disadvantages outweigh advantages then adjust your pacing style.

Sometimes you may have beliefs that make it harder to change your pacing style. Set yourself behavioural experiments to see if these are true.

Your new helpful pacing style:

·         Make a plan

·         Plan activities in terms of importance

·         Neither push yourself on a good day, or do nothing on a bad day

·         Give yourself a reward for following the plan

Ways to change your pacing style

1.       List activities you do, and how long you can do them  on a recent good day and a recent bad day

2.       Write down the number of minutes you could realistically carry out activity every day despite the pain

3.       Write down the number of times you could repeat the activity. It may help to break down the activity into smaller activities

Activity	Good day	Bad day	Every day	Times per day
Ironing	40 mins	0	10 mins	2
Standing and cooking

When you have an idea about your pace then write out a day plan with your activities in it

Do you have any barriers to your new plan, if so how can you respond to them?

Chapter 9 Getting fitter and being more active

Being more active is vital to managing your chronic pain.  To be more active can mean just doing an existing activity faster, longer or more frequently. Rest is useful in the initial stages of pain when there is tissue damage, but it is only beneficial for 1-3 days.

Common sense says we judge our level of recovery by how much pain we feel, but this approach is not helpful.  As hurt is not the same as harm.

As you get fitter you might feel new aches and pains but with chronic pain this is less likely because you are injured again but more likely your muscles are unused, your ligaments, tendons, joins and scar tissues have become stiff.  So actually it’s more likely you have done too much too quickly, so if you do new exercise and it hurts you need to carry on doing it, but just in smaller amounts.  If new pain makes you think you’ve injured yourself and you are back to stage one and stop then you will not make your body flexible and stronger and it won’t be able to move.

Often with chronic pain, people who feel the pain stop. But then they don’t get better, more flexible and stronger to get back to their existing way of doing things.  The longer you rest the harder it is to get going again

What are the advantages and disadvantages of increasing your activity level? Activity produces endorphins, makes muscles and soft tissue flexibles, strengthens muscles giving you energy, stamina and strength

Benefits due to changes in activity levels may be noticed after a few days but the main effects come after a few weeks.

You don’t need a gym, or to play a sport to become more active. The world around you offers opportunities, use stairs rather than lift, walk rather than take the bus, get off the bus a stop earlier. Having more activity in your day, e.g. home management and leisure activities.

Varying the type of physical activity is really useful to ensure your whole body gets more stamina, strength and flexibility.

On your new exercise regime make sure you warm up and cool down.

Do the stretches, don’t bounce hold for 5-15 seconds.

Chapter 10 Problem solving

5 Steps

1.       Recognise and define the problem (emotions are secondary states in response to things, the things are the problem, break big problems into smaller problems)

2.       List all possible solutions

3.       List advantages and disadvantages of each one, short term and long term

4.       Choose the best solution (work out any obstacles, think about time, money, skills, how you will do etc)

5.       Review (Praise for effort rather than achievement)

Chapter 11 Understanding sleep and sleep problems

Write a sleep diary, understand your thoughts and beliefs about sleep

Adults never need more than 9 hours sleep. Some people report feeling refreshed after 5 hours.

Teenagers need 10 hours sleep

Adults 40-60 need 6/7

Adults age 60 need 5 to 6

You can feel fatigue due to inactivity.

Base your sleep needs on how things currently are, rather how they have been, hence keep the diary

Pain and sleep

You wake through pain can make you tense

Pain meds can make you drowsy

At night problems seem worse as time passes more slowly

Being less active changes sleep patterns

Napping during the day, changes the amount of sleep needed

Changing unhelpful sleep routines

We have a natural rhythm when we feel more awake or more asleep, the circadian rhythm, If we sleep in line with this we can have a more satisfying sleep. Get a regular pre midnight time to go to bed. Only sleep in bed or sex, no other activity. Have a wind down activity, put the day aside, do a relaxation exercise, have a bath. Don’t do vigorous exercises late at night, or have fags, booze or coffee. Avoid a heavy meal

Chapter 12 Relaxation

Relaxation is allowing your muscles and mind to slow down and relax. Tense muscles cause pain as they stretch past where they want, they also can’t be used as well as relaxed ones, so that decreases activity.

Relaxation can be active or passive, active could be going for a walk, passive could be a hot bath.  Active could be Xbox, passive could be meditation.

Quick relaxation, notice tension in muscles and let go

Relaxation may not be good for you if you have an acute medical condition, untreated PTSD or psychosis.

Chapter 13 Pain communication and relationships

If you are looked after too much, it is difficult to become independent, feel useful, build your muscles and become more active. Withdrawing from others is a common response when you feel chronic pain but can lead to loneliness and isolation.

People with chronic pain can feel angry, frustrated and this can get in the way of having relationships. Avoid mindreading what someone in pain wants.

People in close relation to the person in chronic pain may well have many adjustments to make for themselves due to the persons pain. With partners it can be useful to just allow them to talk for 5 minutes without being interrupted and then you do the same.

People will be sympathetic in the short term to your pain behaviour but mostly it will wane in the long term.  In the longer term people need to know what you are trying to achieve.

Beware of short term pain relief that keeps the pain going.

Communicating with loved ones tell them

1.       What is hardest about living with your pain

2.       What makes things easier

3.       What makes things harder

4.       What it is you most need help with that you aren’t getting

Sex and pain

·         Much pressure put on your life and your relationship can lead to sex being needed more

·         Must\should thoughts + negative predictions about sex can get in the way

·         Trying different things, pacing can help

·         Talking about how things are for each of you can help

·         The person who isn’t in pain, should be more dominant, more active

Chapter 14 Managing, depression, anxiety and anger

Persistent pain can lead to anger, depression and anxiety

Chronic pain can lead a feeling of helplessness, and hopelessness for the future

Vicious cycle

Lack of control over pain at times

Feelings of helplessness

Exaggerations of how bad my pain is

Pessimistic for the future

Do less, body atrophies

What contributes to depression?

Losses

Substance abuse

Reduced meaningful activity

Depression affects the five systems in SETB and can also be improved by them

People with chronic pain may have thoughts that they are helpless or useless and have behaviours of avoiding people.

Unhelpful thinking styles

Making extreme\statements rules

Personalisation

Bearing all the responsibility

Bias against myself

Putting on a negative view of things

Negative mental filter

Catastrophic thinking

Mind reading

Treatment

Action 1 Identify unhelpful thinking styles

Action 2 When you notice an unpleasant emotion, notice the matching unpleasant thought, then challenge it using a thought record

Action 3 Use the challenging thought work sheet, situation=>thought=>emotion=> does it make sense to think like this=>reformulation

Other ways to manage depression

1.       Mindfulness

2.       BA

3.       Becoming more physical

Part 2 managing anxiety

Action 1: Identify unhelpful thinking styles

Action 2: Challenge unhelpful thoughts

Action 3: Use helpful coping self-talk: Feeling of anxiety is normal, it’s just adrenaline in the body, these sensations will pass

Action 3.5 Use relaxation techniques

Overcoming avoidance

Avoidance maintains anxiety as it doesn’t learn that either the prediction isn’t true or that there isn’t a long term gain, e.g. if I bend it will hurt, short term gain, it won’t hurt, long term gain: a body that can’t bend, so long term cost is that I don’t strengthen my body.

Unhelpful behaviours

Ingesting caffeine (2 or 3 cups of coffee a day)

Not allowing enough time for a job

Part 3 Managing anger

Effects of anger: focus on pain, tense muscles, making them more susceptible to strain

Dealing with anger

Share feelings without blaming

Trying to get justice in a respectful way

Seeing the other persons point of view

Deciding to stop plotting revenge

Action plan 1: Write down how your anger affects other people

Coping plan 1 coping with first rush of adrenaline

Use breathing or muscles to relax

Move to a problem solving approach

Coping Plan 2.

If anger rises then take a pause, breathe out first to increase relaxation. If you breathe in first then this can increase tension. Make out breathes 4 and in breaths 3 and do this for 2 mins.

Coping Plan 3.

Ask yourself : what’s making me angry, have I listened properly, have I got my facts straight, have I got the whole story, have I understood how the other person things, have I jumped to conclusions, is it worth getting angry about this. Think about the effects of anger on yourself and your life.

Coping Plan 4

Useful coping self-talk: If I don’t get angry I will be in control. I don’t need to prove myself. They are trying to get me angry but I can deal with it.

Coping plan 5

Going into a situation that you know could make you angry:

1.       Tell yourself you’ve dealt with it before

2.       Don’t take it personally

3.       Empathise

4.       Action

a.       Deep breathe if you feel anger rising/muscle relaxation

b.      Thinking: ask what’s making me angry, have I listened, have I jumped to conclusions, is getting angry worth the effects

c.       Using coping self-statements

5.       Post event

a.       If item is settled

                                                               i.      Then notice how you helped manage it without anger

b.      If the item is unsettled

                                                               i.      Focus on what well for you.

                                                             ii.      Learn how you could handle differently what didn’t go well

                                                            iii.      After this has been done, let it go

Write down a personal coping plan for anger, include how to handle anger should it arise, things you do and don’t want to do, if you are more vulnerable to anger, e.g. you are tired.

Chapter 15 Acceptance

When life doesn’t meet expectation and the gap between them can cause pain.

When someone offers you a gift you accept it. When there is a negative event you want to change it or yourself. Another approach is to accept it in the same way you accept a gift. You don’t have to like it! Just accept it, without judging or criticising it, or wishing it was different.

I cannot avoid pain, but I do not have to suffer

Pain Management with attentional control or mindfulness

Focussing on pain can open the pain gate, so turning your focus onto something else, probably not you, can be a useful way to manage pain

Three mind states people bring to situations

1.       Think reasonably

a.       Uses logic

2.       Think emotionally

a.       Uses emotion

3.       Think wisely (Being mindful)

a.       Pay attention to the pleasant and unpleasant with equanimity

b.      Avoid making value judgements about themselves, the world or others

c.       Balance their emotions with their logic

Mindfulness skills

1.       Observing

2.       Being non judgemental

3.       Focusing on one thing

4.       Doing what works

Observing

Observe without necessarily trying to stop them even if it is painful

Being non judgemental

Describe without judging

Focusing on one thing

Control your attention, stay in the present, stay on one thing at a time

Do what works

Aim for your goals and for repeatable improvement

Treat things as they are not as they should be

Mindful exercise: breathing mediation

Observing exercise: be aware of your hand on a cool surface, try to sense you stomach and shoulders, watch the first two thoughts that come into your head

Non-judgemental exercise: Imagine your thoughts like a conveyor belt, and imagine putting the thoughts into different category boxes, thoughts about others, myself, the world

Applying this to pain then

1.       When in pain focus on something else rather than the pain

2.       If the pain intrudes accept it without judgement

Chapter 16 Maintaining progress and managing setbacks

Maintain progress by

1.       Change activity routine when it becomes boring

2.       Do fun things to keep active

3.       Steadily increase activity

4.       Reward yourself

5.       Set yourself short, medium and long term goals and reward yourself

6.       Pace yourself

7.       Prioritise especially on the bad days

8.       Learn a new skill

Obstacles to progress

1.       Lack of time

2.       Interruptions

3.       Lack of motivation

Setbacks are when you get a severe disruption to your routine by days or weeks, which can be caused by an increase in pain or by emotional or practical things.

Manage a setback

Reduce your activities to the severity of the setback, but do not stop them, somewhere between 40-50% and increase relaxation skills.

Also for pain, use hot\cold packs whichever feel better. Cut all activities by 40-50%, i.e. specified exercises and standing, sitting walking etc. Work out what helped to manage a setback when you’re in it, and you can reuse this next time. You can then work out a plan for next time.

Chapter 17 Looking to the future and Managing work

It is possible to change the impact of pain, and you need to do this steadily and slowly.  It can be helpful as you make small improvements so keep a Positive Data Log to support this. Use a scale to rate your ability to manage your pain, and fill it in every week.

What out that

9.       You don’t discount achievement by saying it wasn’t down to you

10.   That you ignore achievements by not seeing them

11.   That you don’t distort or dismiss the evidence.

People manage pain better when they are doing something they value. So finding and doing what is important to you is a good pain management strategy

Job brokers like Shaw trust can help people who have been off work for a long time. Build confidence with volunteering and courses.