Today’s post is a practical one. The scientific evidence for interdisciplinary pain management using a cognitive behavioural approach is pretty strong now (e.g. Guzman, Esmail, Karjalainen et al. 2001; Guzman, Esmail, Karjalainen et al. 2002; van Geen, Edelaar, Janssen et al. 2007) although the components that make it effective are not yet known.
One suggestion for why these programmes work is that they help people develop a new attitude towards their pain – it’s no longer a frightening, dominating experience that controls life, rather the person becomes more aware of their options, develops a sense of optimism and starts planning and taking steps towards the future.
Part of this change of focus from ‘patient’ to ‘person’ involves developing a plan. The kind of plans I’ve used consider multiple domains, and involve having a range of actions in each domain, so the person can choose something to use in any given situation – in a flexible way, rather than a rigid prescriptive way.
These plans usually consider the following domains (in no particular order!):
- Thinking patterns
- Ways to manage physiological arousal
- Exercise and stretches
- Ways to manage sleep
- Activity management
- Goals and planning for the future
- Mood management
Under each of these headings, the person can identify a series of actions to take, after becoming aware of their own vulnerabilities and strengths.
The underlying assumptions of the cognitive behavioural approach to pain management are:
- 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)
It seems from research by Amanda Williams and colleagues that the specific skills a person uses don’t really matter – I blogged about this a couple of weeks ago, that in fact people don’t use pain management skills (or at least don’t recall the skills they draw upon) at 1 year after a programme. I think it’s probably that attitude change, and the increase in self efficacy that helps the person develop a sense of optimism.
I’m not sure whether developing specific skills in goal setting is as important as having a goal to work towards – or at least having the sense that things the person values can be achieved in some fashion. I also think that a shift from ‘waiting for someone to do something’ to ‘what can I do’ makes a big difference. This refers to internal versus external locus of control. If the person doesn’t learn to make things happen and take responsibility for doing so, then all sorts of barriers and obstacles will be in the way of progress.
I’m not sure we can ‘make’ a person move from feeling demoralised and defeated, with an external locus of control. I think the process of engaging in activity, of feeling that there are options that the individual can do to make life different, and something about identifying abilities that are unaffected by pain might be a big part of that process. Perhaps a lot of the positive gains from participating in pain management programmes is about developing this sense of being more than the diagnosis.
Just as there are many different factors that lead someone to develop long-term disability associated with chronic pain, there will be many factors that will help that person move forward again. Part of this must be developing a sense of life being worthwhile even though pain is present – I suppose ‘acceptance’ is the best word for it. It’s something about not being defined by pain but being defined by who the person is, and not what they can or cannot do.
At the moment, it seems that the best way to help someone who has ongoing pain and disability is to help them develop this sense of optimism, and belief that they are still valuable, and that it’s up to them and their family to recognise and nurture this new identity. Perhaps that’s a good part of what we do as health professionals – we don’t accept that life with pain is completely hopeless, and we honour the belief that people are much more than what they can and cannot do. Maybe the ingredients in a pain management plan are less important than just having one.
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Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation
for chronic low back pain: systematic review. BMJ 2001;322:1511–16.
Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary bio-psychosocial
rehabilitation for chronic low-back pain. Cochrane Database Syst
van Geen J, Edelaar MJ, Janssen ME, et al. The long-term effect of multidisciplinary
back training. Spine 2007;32:249–55.