…with apologies to the therapists in the Special Interest Group who first raised this topic!
Something I’m acutely aware of after working in pain management for a while is the number of assumptions that I hold about what people ‘should’ know about pain…sometimes I can be quite rightly accused of leaping waaaaaaay ahead of what people are ready for in terms of new information! So it’s time to summarise the ’10 things you really oughta know about chronic pain’ In My Humble Opinion.
1. Pain is a biopsychosocial experience, that it’s “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” and what that means in real terms. I think it’s important to recognise that the experience of pain can’t be divided into bio – psycho – social, it’s all of these combined, because without any one aspect, it’s not pain. Oh and the ‘nociceptive system’ can’t finish at the thalamus and be called ‘pain’.
2. The neurobiology of pain involves the entire body system – and while we can begin at the periphery and work inwards, probably we should begin in the brain (and especially noting the function of the brain to protect us) and work outwards. As Lorimer Moseley reminds us – for every ascending fibre, something like 600 descending fibres are present. This means to me that trying to understand pain without considering the brain’s role is a bit like the infamous fish and a bicycle.
3. There is a difference between acute and chronic pain – but the delineation of them is probably fuzzy. And it’s probably true that duration isn’t the most useful way to define when pain is chronic, and overall, the management of both eventually turns into ‘use your body as normally as possible’.
4. NOT moving and doing things normally is the Enemy of Recovery – but you can’t go at things in the same way as before you had the chronic pain. ‘Normal’ might mean slowly and gradually increasing activity levels, and usually means working hard on not just movements but also thoughts and emotions – and interactions with other people. This is what the medical profession mean when they say ‘I’m sorry there is nothing I can do for you, you will just have to go and learn to live with it‘. Learning to live with it does not mean ‘go back to how you used to be and pretend to ignore your pain’, it means developing new ways of viewing yourself and your activities and communicating this with others. This is not easy.
5. Biomechanical and organisational ergonomics make no difference to the prevention of and recovery from low back pain. That wonderful ‘ergonomic’ chair and ‘ergonomic lifting technique’ – it simply does not change the fact that humans get low back pain, and most low back pain recovers a bit then grumbles on. It’s nice to have shiny new ‘ergonomic’ interventions, but maybe they play more of a role in employee satisfaction through ‘nonspecific’ effects than through the intervention itself.
6. Anxiety and especially anxiety related to having health problems or pain, and most especially anxiety leading to avoidance of activities that might lead to pain – everyone from primary care doctor to case manager to acute care physiotherapist to health staff in hospitals to therapists like me need to know about anxiety and how it can blossom into full-on avoidance. It’s not so much the anxiety that is the problem – because you can be very afraid of something, but do it anyway, and the fear drops if you stick with it. It’s avoiding things because of anxiety that creates the major issues – because by not testing the waters and actually doing something and coping with it, the person maintains anxiety and it could well continue to get worse.
7. Distress and disability and seeking care or treatment for pain doesn’t necessarily mean the person’s pain is higher than someone else. Treatment seeking isn’t straightforward, and it isn’t always about how much it hurts. It’s often about feeling really worried about the meaning of the pain (Is it a tumour? Is it going to stop me from working? Will I need an operation?), it can be about a paperwork system that requires a doctor to complete a form, it could be to stop someone else from worrying. What this means is that focusing ONLY on how painful the problem is probably leads to unnecessary intervention targeting pain intensity rather than interventions that work on the disability and distress.
8. Graded reactivation, graded desensitisation and graded exposure ARE NOT THE SAME THINGS! Reactivation is about gradually increasing activity levels on a quota basis, giving the person lots of warm fuzzies and positive reinforcement for achieving the targets and maintaining them. Graded desensitisation is about gradually increasing the sensory input to an area while the nervous system adjusts to and recalibrates the pain ‘setpoint’ – it’s been used forever in burns rehabilitation. Graded exposure is about developing a hierarchy of feared situations/activities, then helping the person engage with these situations to disconfirm their hypothesis that it will end in some sort of disaster. Graded exposure is the one pain management clinicians have ‘borrowed’ from psychology and the treatment of phobia.
9. Pacing does NOT mean doing less so you don’t trigger a flare-up! It means working to a quota that is easily managed on a ‘good’ day, and a bit of a stretch on a ‘bad’ day (do no more on a good day, do no less on a bad day), and it should be gradually titrated upwards as the brain habituates to the new sensations. It is NOT ‘do 80% of what you can do’ because 80% of zilch is zilch!
10. Psychosocial yellow flags are a set of factors associated with chronic disability related to having chronic pain. They are not signs of malingering, nor of being a ‘poor coper’, they are not psychiatric, and they don’t always need to be managed by a psychologist. They ARE present in all of us to a certain degree! It’s the combination of, or the degree that any one of them has to influence disability that is the real problem of chronic pain. People with ongoing problems with pain often don’t have incredibly high pain intensity – what they do have is incredibly serious disability, or the limitations arising from their pain. And it’s the disability that means people stop doing things, have poorer mood, not so great relationships, issues with living the life the person wants to lead. Perhaps our focus should go from the pain and focus instead on what the person can and cannot do.
…then there is ‘a cognitive behavioural approach’ in chronic pain is NOT the same as ‘cognitive behavioural therapy’ for mood (although it’s based on many of the same principles)
…medication is not as wonderfully effective as we’d all like to think (maybe 30% reduction in pain?)
…darn it, I’d better stop!
Apologies to the therapists from NZAOT SIG – this idea was too good to be kept to ourselves!