A self-management approach to coping with your pain?

1. A self-management approach to coping with your pain? Some people are ready to adopt a new way of coping with their pain and some have reservations. Let’s see where you are regarding your willingness to learn new coping strategies to improve the quality of your life and increase your ability to function.

2. Readiness for Change  Do these statements sound familiar? “I think that my doctors need to take care of me and fix and cure my pain problem.” “No matter what people say about learning to live with this pain, I don’t think I should have to especially with all the wonderful things medicine and doctors can do.” “There must be a reason for my pain and I know that something is seriously wrong and all I need to do is keep looking and find a doctor who can finally figure it out and fix me.” If these statements sound familiar you may not be thinking there is anything you can do to cope better with your pain. You may be thinking there is “no way” you need to handle your pain problem differently. You may not be considering the possibility of change in what you can to do better cope with your pain.

3. Albert Einstein once said, “Repeating the same behavior expecting different results is insanity.” If you want a new and different result, try doing something different!

4. What Motivates you to Change? How about these statements. Do any of these sound familiar? “People are telling me that I have to learn to live with this pain, and I am thinking I may need to.” “Pacing myself and learning better body mechanics probably would help me live a better life with pain, and I think it’s time for me to think about this. “ “I know I should deal with my pain better, but nothing has worked and I am getting very frustrated.” If this sounds like you, then you may be likely to saying “yeah, but” to a self-management approach to pain rehabilitation. You recognize that there is a problem and you are beginning to think seriously about changing what you do to cope with your pain, but you are having a hard time starting.

5. Take Action – “I think I can” How about these statements, do they sound like you? “I have started coping with my pain better and am beginning to exercise and learning to relax.” “I am going to overcome this problem.” “I can say I am getting on with the business of living despite my pain.” “This pain may be with me for a long time so I am willing to adopt new coping strategies for my pain, such as pacing myself better and not overdoing activities.” If this sounds like you, then you may be likely to say “I think I can” and are “ready” for a self-management approach to pain relief.

6. What if I find myself “agreeing” with all three of these sets of ideas? • Don’t worry you are not alone and I encourage you to be open to what this approach has to offer and you may learn some things that can help. • Hang on to these materials because it can provide a resource that you can use in the future. • Not everyone it ready for the self-management approach. You are still OK. Perhaps when times get difficult you can return to the concepts presented in this approach and they will be helpful to you then. • If you are ready, I encourage you to keep these materials as they can be helpful in explaining to others what it is you are doing. • Finally, it is good to keep some hope that the future will bring new types of medical procedures and tests and perhaps your pain can be changed by new future medical technologies. But, don’t put all your eggs in this basket.

7. Intention to Change • “What are the reasons you see needing to make changes in your life?” • “What makes you think that you need to make a change?” • “If you were 100% successful and things worked out exactly as you would like, what would be different?” • “What are the advantages of changing the ways you currently deal with your pain?” • “If you are feeling stuck at this moment, what is going to have to change?”

8. Key Parts of the Self-Management Approach to Pain Relief • Information about your pain generators • Activity pacing/modifying activities • Movement/exercise and body mechanics • Relaxation training • Examining your ideas/thoughts about having pain • Managing medication • Managing mood (depression, anxiety, etc.) • Enhancing Energy/Sleep • Exploring impact of others/Drs./family

9. Information about your pain generators _______ Start pacing/modifying my activities ______ Start movement/exercise and improve body mechanics ______ Learn relaxation skills ______ Explore my ideas about having pain ______ Understand my Medications ______ Manage my mood (depression, anxiety, etc.) ______ Manage my Energy/Fatigue/Sleep ______ Explore impact of others/Drs./family ______ I do not think this activity/task would be helpful to me in my pain management . . . . . . 1 I am not sure if this activity/task would be helpful to me in my pain management . . . . . 2 I think this activity/task would be helpful and I am willing to start. . . . . . . . . . . . . . . . . .3 This activity/task is already useful to me. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Rate the following:

10. How important do you think these activities are to you and your pain management? • Information about your pain generators _______ • Start pacing/modifying activities ______ • Start exercise and improve body mechanics ______ • Launch relaxation training ______ • Exploring your ideas about having pain ______ • Understanding Medications ______ • Managing mood (depression, anxiety, etc.) ______ • Managing Energy/Sleep ______ • Explore impact of others/Drs./family on pain ______ How important is this activity/task in helping you manage your pain? 0 1 2 3 4 5 6 7 8 9 10 Not at all important Very Important

11. How CONFIDENT are you that you can engage in this activity in managing your pain? 0 1 2 3 4 5 6 7 8 9 10 Not at all confident Very Confident • Gather information about your pain generators _______ • Start pacing/modifying your activities ______ • Start exercise and improve your body mechanics ______ • Launch relaxation training ______ • Challenge your ideas about having pain ______ • Understanding your Medications ______ • Manage your mood (depression, anxiety, etc.) ______ • Manage Energy/Fatigue/Sleep ______ • Explore impact of others/Drs./family on pain ______

12. Pain Care Kit:A Self-Management Approach to Pain Relief • You have had pain for quite a while and have been unable to find relief. • Your physicians have looked for the physical explanations for your pain, your “pain generators.” • Your pain initially taught you to rest, lie down and reduce your typical activities. • This strategy allows the tissue to heal. But if healing takes place within six weeks of the injury, why do you continue to have pain?

13. Why do I hurt? • What is causing your pain? Why do you hurt? • Chances are you see your pain the way your physicians do, that is, there is a physical sign or cause of your pain. • You have tissue damage and the amount of your pain you experience is directly related to the amount of tissue damage. • Chances are you have been treated from an acute pain perspective, that is, physical therapy, rest, medications, surgery, and time off from all activities. • If your pain has gone longer than three months you now have chronic pain.

14. Has the “acute pain management” approach worked for you? • Probably not and that is why you are here. • But why hasn’t this approach worked? • Because pain is more than a physical symptom. • The biological perspective alone is too simple to explain all that you are experiencing. • We have relied on an acute model of pain and have failed to realize that chronic pain needs to be treated differently. • Your pain has many parts including your emotional reaction, the reactions of others, sleep problems, energy and fatigue, anger, and negative and counter-productive thoughts about having pain.

15. Consequence of prolonged chronic pain • Pain leads to withdrawal and rest • Isolation leads to inactivity, boredom, fatigue and depression. • With fatigue you become more immobile and believe that rest is best. • Bed rest leads to deconditioning. • With little to no distraction, your pain becomes worst. • You take medications to reduce the pain but they lead to side-effects (confusion, poor concentration, drowsiness, constipation, etc.). • The narcotics reduce your own natural morphine-like substances (endorphins). • Over time cycles of pain can emerge that perpetuate the pain. • Your reactions to continuous pain can make your pain worse.

16. Reduced ability to work Reduced pleasure in normal activities Development of pain behaviors Decreased endorphin and seratonin levels Lower self-esteem Increased anxiety, depression, frustration hopelessness, and anger Increased sympathetic arousal Increased muscle tension Consequence of prolonged pain

17. Does this sound like you? Please read on because there is help and hope.

18. “What can I expect from the self-management approach?” • Keep in mind that the self-management approach will not produce “miracles” but instead you should see gradual and steady improvement. • You will have to participate in all lessons and work outside of the treatment sessions. • You control the outcome and even if your results are slow in coming have patience and you will reach your goals. • The self-management approach has been shown to be effective for about 70%-80% of people using it. This is because it is customized to your unique needs. • The main treatment goals are to improve the overall quality of your life and increase your ability to function and do things.

19. Starting point: How are you doing now with your pain?Tools for Measurement • How can we tell if the self-management approach is working? • Feeling better is the best gauge, but here are other means to measure your success: • The “Pain intensity rating scale” or Yardstick • Results from your responses to the BAP (Behavioral Assessment of Pain questionnaire)

20. Measuring your pain intensity • Pain management starts by measuring the problem with the “Pain gauge” • We will use a 0 to 10 pain rating scale • 0 is no pain • 10 is unbearable pain • 1 through 3 is “functional” • 4 through 7 is “uncomfortable” • 8 through 9 is “severe”

21. Pain Intensity Scale Mild Moderate Severe

22. Pain Scales 0 1 2 3 4 5 6 7 8 9 10 Mild Moderate Severe The association between pain and disability • Pain Pages 307-314 Judith A. Turner, Gary Franklin, Patrick J. Heagerty, Rae Wu, Kathleen Egan, Deborah Fulton-Kehoe, Jeremy V. Gluck and Thomas M. Wickizer

23. Pain Yardstick • Use this pain rating scale throughout the program to measure your pain levels. • Pay attention to the words under the numbers to guide your estimates. • Make sure that the number you choose agrees with the way you are feeling and matches the words below the number.

24. Assessment of your unique and personal pain experience • Without a careful evaluation we do not know everything there is to know about your unique pain experience • A careful assessment and analysis is essential in the development of your individualized pain management plan for change.

25. Complete the Behavioral Assessment of Pain questionnaire

26. Feedback on your pain experience from the BAP • You will get your individual scores on 36 different clinical areas impacting people with chronic pain and be able to compare them to the normative sample (1,000 other people who have chronic pain). • You will be able to tell if your scores are above the “normal/typical” range or below this range. • Elevations on these 36 areas of pain assessment are predictive of long-term risks for disease, disability and chronicity. • Scores below the average range compared to the national sample suggest these are your assets and personal strengths while having chronic pain.

27. Behavioral Assessment of Pain Questionnaire: Results • Review the Summary section of the BAP • Examine your “Areas of Concern” section • Take credit for your “Assets for pain management” • Examine your T-scores and develop your “Areas of Concern and Assets sheet”

28. Results • Review the Summary sheet page of your BAP results • List all areas that are above a T-score of 55 These are areas for treatment intervention and concern. • List all areas that are below a T-score of 45 These are your assets for pain management.

29. The Bell shaped curve (----------------68%--------------) Most (68%) people in pain score within the range of 40 to 60 20 30 40 45 50 55 60 70 80 T-scores

30. Ranges of the Curve 20 30 40 45 50 If the T-score you are reviewing is 45 or below, clinically you are below the clinical average compared to the national sample of over 1,000 other people in pain. A T-score of 50 is an average score for this sample.

31. Ranges of the Curve 50 55 60 70 80 If the T-score is 55 or above, clinically you are above the average when compared to the national sample of over 1,000 other people in pain. A T-score of 50 is an average score for this sample.

32. Areas of Concern: (T-scores above 55) ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ Your Assests: (T-scores below 45) ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ “Areas of Concern and Asset sheet”

33. “Areas of Concern and Asset sheet continued” • Areas of Concern: (T-scores above 55) • ____________________ • ____________________ • ____________________ • ____________________ • ____________________ • ____________________ • ____________________ • Your Assests: (T-scores below 45) • ____________________ • ____________________ • ____________________ • ____________________ • ____________________ • ____________________ • ____________________

34. How to interpret • What do you make of your BAP results? • Is this what you expected? • Are you starting to wonder what you can to differently about your pain?

35. What has Chronic Pain taught you? • The more I do the more I hurt. • If I hurt it means I am harmed and injured • Rest is best and will make me better • If I am doing anything that is hurting or making me feel sore and achy, I should stop, not move and lay down and rest.

36. “Hurt does not mean Harm.” • When starting a pain management program the initial steps will be difficult since you likely have not done much physically. • Anticipate some normal soreness and stiffness with increased physical exercise and movement • Remember that “hurting” is normal but harm is not. If you believe you have harmed yourself, that is, the pain is in a new area or is more intense that usual, you need to stop and get medical attention.

37. “The more I do the more I hurt.”

38. “The more I do the more I hurt.” • The false message here is that your pain is teaching you not to move or do the things you use to do. • Chronic and persistent pain cannot teach you to stop all activities and rest or your problems will magnify • You need to learn how to “modify” your activities given your pain condition.

39. “How much rest do I need?” • Bed rest is usually recommended for acute low back pain. • Compared two days of bed rest versus 7 days of bed rest. • Found: for people without neurologic deficits, two days of bed rest had no difference in clinical outcome than those told to say in bed 7 days. • Implications: early mobilization of people with back pain. • “How many days of bed rest for acute low back pain? A randomized clinical trial. Richard Deyo MD. The New England Journal of Medicine, Oct. 23, 1986.

40. “The Disuse Syndrome” • Cultural sedentariness is the base of our human ills. • Physical inactivity predictably leads to deterioration of many body functions. • Key characteristics include: obesity, cardiovascular vulnerability, musculoskeletal fragility, depression and premature aging. • Principle of Least Effort: when an organism has a task to perform it will seek that method that demands the least effort. (examples; wheel, pushbutton tuning, horizontal escalator, golf cart). • Walter M. Bortz II, The Disuse Syndrome. Western Journal of Medicine 1984 Nov; 141: 691-694

41. Structural/Functional responses to Disuse • Musculoskeletal: decease in fiber diameter; increase in urinary nitrogen content; protein loss of 8 grams per day. • Cardiovascular: 40% less maximum oxygen intake; cardiac output, stroke volume, left ventricular function decrease with disuse; systolic blood pressure rise. Plasma volume falls 10% to 15% with bed rest. • Paul J. Corcoran, MD. Use it or lose it – The hazards of Bed Rest and Inactivity. Western Journal of Medicine. May 1991 pp. 536-538

42. Structural/Functional responses to Disuse • Joints: contractures; loss of normal range of motion • Bone: osteoporosis • Psyche: anxiety, depression, anger

43. Disuse problems • Blood Components: red cell mass decreases with inactivity • Lungs: decreased capacity • Inactivity plays a pervasive role in our lack of wellness. • One of the most extraordinary aspects of the human body is its resilience: its ability to recoup is enormous. There is still time to turn it around.

44. Why is treating chronic pain like acute pain a problem. • It causes you to become dependent on others to do things to you • You take a passive role • External locus of control • Rest and inactivity are inappropriate for chronic pain • By definition, chronic means no success in the acute phase.

45. Treatment for chronic pain is very different from acute pain • When pain continues for over 12 weeks we call it chronic pain. • Traditional methods for treating acute pain do not work with chronic pain. • Such things as resting and avoiding activities only makes pain worse when pain becomes chronic. • But what are the differences between acute and chronic pain?

46. Acute pain management 0 to 12 weeks Short duration Symptom of tissue damage Treatment: correct damage, rest and medication Example: broken leg or appendicitis Expectation: cured/fixed/relieved Useful signal of danger and something is wrong Minimal life disruption Chronic pain management 13 weeks to years Long duration Not a symptom but “the” problem Treatment: movement in a graded fashion Example: low back pain accompanied by depression, anxiety, sleep disturbance Expectation: to management Pain signal may be the problem and not a sign of tissue damage Significant life disruption Acute vs. Chronic pain

47. Shift from Acute to Chronic pain management • The prescription of rest and inactivity is inappropriate for chronic pain condition. • The effects of disuse and inactivity become part of the problem and not part of the solution.

48. Three reasons why disuse and inactivity make pain worse • With disuse and inactivity, the muscles become weaker and less flexible. Consequently, any physical demand strains and fatigues the muscles sending pain signals to the brain. The trap is that the pain suggests a need to rest when in fact just the opposite is true.

49. Three reasons why disuse and inactivity make pain worse 2. With inactivity there is a loss of productivity and feelings of helplessness, defeat, frustration, anger and dissatisfaction. There is almost always a loss of activities that were rewarding and enjoyable and we know this lead to depression. Vicious cycles start.

50. Three reasons why disuse and inactivity make pain worse 3. Exercise seems to stimulate the body’s natural defense against pain through natural pain relieving substances (endorphins). Researcher has consistently found high levels of endorphins in athletes and low levels in inactive people and chronic pain patients.