Making the most of a referral for pain management


This is a post for people who may refer someone for pain management, or someone who is personally being referred. When I talk about pain management, I’m meaning a multidisciplinary or interdisciplinary pain management programme where participants learn about their pain, develop strategies to cope with life despite their pain, and get involved in reactivation.

The contents of a cognitive behavioural pain management programme (eg INPUT, ADAPT, vary considerably – it’s essential that the approach includes these concepts:

  • That clients can learn to accept the chronicity of their pain.
  • That clients can change their relationship to their pain in a way that allows them to broaden their sense of identity/self beyond the pain to that of “a well person with pain”.
  • That clients can learn or re-explore skills to deal more effectively with their pain, e.g., relaxation training, activity-rest cycling, graded exercise, attention management. (Morley, Biggs & Shapiro)

A programme typically includes the following:

  • information about the model of chronic pain, differentiating between hurt and harm, the biopsychosocial model
  • graded reactivation, often through exercise, but also through other activities
  • self regulation training to reduce physiological arousal
  • cognitive therapy to work with thoughts, emotions and behaviours related to pain and new skills
  • activity regulation including activity quota, task persistence and activity planning
  • communication skills including assertiveness, reducing pain behaviour and positive language
  • goal setting, relapse prevention and ways to encourage maintenance of the new behaviour

Most programmes are for around 3 – 6 weeks, and usually include at least one follow-up session.  Team members come from a number of different disciplines: occupational therapy, physiotherapy, psychology, nursing, social work to name a few.

Participants are usually carefully screened before they are included on a programme. This is to ensure their expectations, and their goals, are appropriate for the intent of the programme.  A programme that aims to help people become more active despite their pain is probably not going to be helpful if a person is still seeking pain reduction, or a ‘cure’, or perhaps still holds an acute model of their pain.

Some people don’t work well within a group setting – while a pain management programme isn’t ‘group therapy’ like the encounter groups of the 70’s, people still have to be comfortable talking about themselves in a group setting.  They need to be aware of and able to cope with group behaviour (listening to each other, allowing for different viewpoints, holding onto confidentiality and so on).

So, now that you have some idea of what a pain management programme looks like, to make the most of a referral, you need to think of the following:

  1. Pain management is about developing skills, not reducing pain. Learning new skills takes time. We ask a lot of the people on a programme, and it’s unlikely they will leave a programme immediately able to use all the skills and be completely different from before.  This means it’s probaby helpful to have a period of time (perhaps a month) from the end of the programme before any new initiatives are started. This doesn’t mean leaving the person alone, but perhaps it would be best to delay starting a new return to work programme for the first month.
  2. Learning new skills requires motivation, or ‘readiness’ to act on the new information. It’s a bit like alcohol and drug rehabilitation: the person needs to want to use the skills, and there is no point ‘making’ someone attend if they’re not in the right mindspace.  This is where the stages of change model is so helpful, and using motivation interviewing can be a great way to help someone consider their choices as they begin to think about where they are today and where they want to be tomorrow.  If a person still wants a cure or pain reduction, it’s probably not the right time for pain management.
  3. Because it’s a process of learning, most participants will slip or lapse shortly after completing a programme. This isn’t a disaster, but it does mean the person will need support.  Support to make specific plans for the month immediately after the programme, and support to continue with those plans despite problems.  These plans should be focused around integrating the strategies developed during the programme.
  4. Pain management programmes don’t usually target return to work – and unless they do, the person will still need help to return to work. People who develop pain management strategies that work well at home may find it quite difficult to use the same strategies at work. This can be because at work it’s hard to feel OK about working to a quota instead of to a deadline, it’s often more difficult to stop and stretch because others in the workplace may notice, or the power difference between the manager and the worker means it may be difficult to suggest different ways of working, or be assertive about situations.  Specific assistance with using pain management strategies at work should be provided at the same time as return to work attempts.

Close liaison between the team members involved with helping the person return to a normal life is vital. This team needs to include the GP, someone from the pain management programme team, a case manager or someone from the workplace, and any other treatment providers involved from the community.

Pain management programmes have been around for 30-something years now. Their worth is clear, although some still argue about the cost-effectiveness of them. Provided that everyone is clear about what the programmes can and cannot do, they have been a breakthrough for people with chronic disability associated with pain.

2 comments

  1. I suggest you reach out to people that really need your services for pain management. Exceptional Parent magazine is a communication resource for families and professionals involved in the care of those with disabilities many of whom have conditions such as incontinence, spinal cord injury, or other medical conditions which effect the day to day activities of a person’s day to day life. They offer classified ads that are very inexpensive to reach out to 500,000 individuals, many of whom have special needs, and the magazine is also on every military base.

    prothbein@eparent.com

    1. Hi Paul
      thanks for this. This blog isn’t aimed at people with chronic pain, although lots of people do read it, but more for the therapists and other health professionals working with people who have chronic pain.
      Thanks for taking the time to comment, and I wish you all the best.
      Bronnie

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