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.
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