Changes take energy – that’s nothing new, I know, but perhaps something as clinicians we might forget when we work with people who have chronic pain. I was thinking about this as I’ve had a week away from regular blogging so I could focus on writing and some self care. Things are busy and as we enter the run up to Christmas, not likely to slow down any time soon – and yes, this takes energy!
Adjusting to living with a chronic health problem is demanding, it’s complex and requires people to reflect on what is important to them, how to achieve important activities all the while maintaining a sense of self. Self regulation is a term used to refer to the ability to alter thoughts, feelings, and behaviors. In chronic pain ‘[the] demands cross biopsychosocial boundaries and include managing the pain itself (e.g., by redirecting attention or exercising), negotiating close relationships that can be affected by the limitations associated with chronic pain, suppressing ruminative thoughts about pain, and regulating moods such as depression and anxiety that are commonly comorbid
with pain.’ (Solberg, Roach & Segerstrom, 2009).
I’m not sure that we generally acknowledge the fatiguing aspects of all this adjustment – and I reflect myself on how I respond when someone says they’re tired, I usually start to think about whether the person might be depressed, what their sleep might be like and so on, but rarely ponder the extent to which adjustment and self regulation might be a finite resource that requires replenishment from time to time.
Solberg, Roach and Segerstrom state that ‘Executive functions, largely orchestrated by the prefrontal cortex (PFC), are “a collection of interrelated abilities that enables people to modify their thoughts and actions”’. Executive functions vary both in terms of general ability and specific ability to regulate thoughts and actions. Use of a portion of the brain to self regulate (eg suppress thoughts or emotions) reduces the ability to carry out other cognitive functions such as reasoning. ‘Acts of self-regulation (e.g., attention control, emotion control) led to poorer higher order intellectual performance on tasks involving logic and reasoning, cognitive exploration, and reading comprehension.’
It’s already recognised that some chronic pain conditions such as fibromyalgia and temporomandibular disorder not only present with pain, but also affect cognition, emotions and physiological functioning. People commonly report being fatigued, having ‘fibro fog’, and present with a range of other problems including disruption to sleep. The authors of this paper point out that many of the same brain regions that are affected in chronic pain are also associated with executive function such as cortical blood flow to thalamus, the caudate nucleus, and the anterior cingulate cortex and gyrus. Whether these changes are cause or effect matters less than to recognise that they are present and functionally suggest that people with chronic pain may also have trouble with self regulation.
Importantly, self regulation can be developed. Active coping in chronic pain is almost all about self regulation – setting goals, persisting in certain tasks, halting others, managing emotions and so on. The ability to sustain these activities varies considerably and I’m sure we’ve all encountered people who have managed well for a time, but lapsed or had a major set-back due to another significant event. Important to remember is that ‘if patients with chronic pain are already experiencing self-regulatory fatigue, they have little strength to initiate or maintain such activities, regardless of their potential benefits.’
Maybe one part of the success of graded reactivation is not so much the habituating to pain, nor even the ‘return to fitness’ that is now being challenged (just how fit are the therapists compared with the participants who have chronic pain?!), but because it doesn’t tax the already fatigued self-regulatory resources.
The paper I’ve been quoting from provides a helpful, albeit brief, review of self regulation, executive functions and chronic pain. Recommended reading if you haven’t considered the area before, and also because it summarises a good deal of the neurophysiological information and self regulatory literature and applies it directly to the areas we are concerned with in chronic pain management.
This week I’ll be focusing on self regulation – there’s much more to learn! I think it may well be a significant part of resilience, and therefore worth developing not simply in people with chronic pain, but maybe in ourselves as clinicians. Who knows, some of us might be both!
Solberg Nes, L., Roach, A., & Segerstrom, S. (2009). Executive Functions, Self-Regulation, and Chronic Pain: A Review Annals of Behavioral Medicine, 37 (2), 173-183 DOI: 10.1007/s12160-009-9096-5