A quick post this morning before I search for some Friday funnies!
I saw a few patients this week after having had just over a fortnight off work – and you know how sometimes working in pain management can seem unrewarding, progress can be incredibly slow, one step forward, two sideways… Well here are some progress reports from some of the people I’ve been seeing (names and details changed to protect identities).
Hypnosis for intermittent phantom pain
First up is a man with a 10 year history of below knee amputation. He wears a prosthesis, is fit and active, and until late last year was working full time. Over the latter half of last year he developed intermittent severe stabbing phantom pain (prior to this he had phantom sensation with some stump pain but never phantom pain). He initially tried to fight against the pain, holding his breath and tensing up – but as the length of the pain episode could be up to four or five hours, he found he couldn’t maintain his work, so has stopped. He’s been working with me and the rest of the team off and on over the past six months, and although he’s tried just about all the medications available, his pain hasn’t changed one iota.
He’s someone who readily took to using mirror therapy, but found that after a couple of months the effectiveness of this wore off, and the illusion that the reflected leg was his own wasn’t as strong. He’s adopted going ‘with’ the pain and breathing through it rather than fighting it, and he’s developed an effective visual imagery strategy that he finds really helpful provided that he’s lying down to achieve it. That kind of gets in the way of the rest of his activities – swimming, going to the gym, cycling and generally living life!
We’re now working on some cued hypnosis, so that while his pain may not be reduced, he may be able to ‘distance’ himself from it, and be able to do this in a range of settings so he won’t need to stop what he’s doing to ‘deal with’ the pain. He is continuing with two more medication trials, but if they don’t change his pain he’s told me he will be no worse off than he is now. Once he’s got his hypnosis ‘portable’ he intends to start looking at his work options.
My reasoning for using hypnosis lies with his strong ability to visualise and imagine his limb, his well-developed relaxation response, the intermittent nature of his pain meaning he needs something he can draw on as required, and that he is looking for something ‘portable’. I’ve started with deep relaxation, moved onto visualisation, then to quick inductions, and now we’re working on strengthing a physical cue while he’s deeply relaxed (pressing finger and thumb together while increasing the suggestion that he’s feeling really relaxed and that while he is aware of things, ‘nothing is bothering him’). The next step is to do what I call ‘porpoising’ which is where we dip in and out of a deeply relaxed state to full awareness, pairing the ‘awareness’ state with the physical cue.
Working on self efficacy for return to work
The next person I’ve caught up with is a man who’s been off work with nonspecific low back pain for about 2 years. When he first came to see us he was very fearful of moving, he thought there was ‘something wrong’ with his back that meant he shouldn’t bend, and he was very deactivated. He used a stick, and walked unsteadily and very, very slowly. As a previously very fit man with a history of competitive team sports and having been in the military, this was an incredibly frustrating experience for him.
As a family, he’d moved from being an earner to being quite settled in the caregiving role for their young child. His wife worked full time but also carried out most of the household activities – including mowing the lawns, cleaning the car, doing the laundry.
This man had no confidence at all in his ability to return to work – he thought his medication would interfere with functioning (and it probably did – he was very drowsy after using meds ‘as needed’), he was fearful of telling anyone about his back pain, and he thought he had no skills for work given that he wasn’t even able to carry out a full day’s household activity. His past employment was physically demanding and he thought he wouldn’t be able to study because of his medication. After completing a self efficacy measure for returning to work, where 1 = ‘not at all confident’ and 10 = ‘completely confident’, over the three domains of ‘managing pain’, ‘asking for help’, and ‘fulfilling job demands’, his average score was just 2.5.
I should add that this man has attended the three week interdisciplinary CHOICES pain management programme, and also had a 12 week individualised programme with myself, physiotherapy and clinical psychology – so he’s had the full house of pain management over about six months.
The part I’ve played has been to review his coping strategies, and identify the ‘obstacles’ to using these at work. We’ve looked at his beliefs about the various coping skills and why he thought he couldn’t use them at work, and identified those that he can and those that are better used when he gets home. We’ve worked on effective communication. We’ve discussed ACC and the process case managers need to follow. We’ve set goals and developed a daily routine. We’ve reviewed setbacks and flare-ups and looked into the chain of events leading to ‘high risk situations’ in which he’s chosen to revert to old habits. We’ve tweaked his suite of coping strategies so that he has lots of options for ‘what to do’ in the event of pain fluctuations. He’s minimised his use of ‘as needed’ medication which has reduced the side effects that do interfere with his functioning. He’s studied and achieved a very good pass in his exams for his chosen field of work – and used the studying as an opportunity to practice active coping, persisting with activities despite fluctuations in pain, and working with his slightly reduced concentration and memory.
Yesterday he turned up in suit, shirt and tie, looking absolutely spiffing. He’s got brochures introducing himself to potential clients. He’s reorganised his life so he and his wife share child care. He’s fit and working towards a specific fitness goal (to play in the Masters tournament). He’s coped with several setbacks – successfully! He’s even participated in a functional capacity evaluation that he knew would temporarily increase his pain – and managed this without reverting to ‘old habits’. On a re-test of his self efficacy for return to work, over the three domains, his mean score is now 9.8.
You know, someone once told me that people with pain are often ‘losers’, or ‘non-copers’. While there are some people who are certainly much more vulnerable to life’s misfortunes, and perhaps haven’t had the advantages I have, the two people I’ve just described are amongst the strongest, most resilient people I’ve met. Maybe their experience with coping with chronic pain has been their opportunity to transform their lives, and maybe I, along with the rest of the team, have been a small part of that transformation. All I can say is that it’s an incredible privilege to work with people like this – and see their progress.