In a very unscientific vox populi survey conducted via my blog, I asked people with pain to tell me the FIVE self-management strategies they’d used over the week prior. If you’re interested in completing this yourself, click here: click. (Scroll down that page to the survey).
My reason for asking the question is that we have a list of self-management strategies, but the definitions and the way strategies are used in daily life are quite murky. For example, we don’t have a clear definition of ‘activity pacing’ though we are starting to investigate it. We also don’t know whether strategies introduced during a pain management programme are those that get carried on over time. We know that movement practices are common, but we’re not certain what forms of movement practice are carried out over a lifetime – and many people living with persisting pain will need to use strategies over a lifetime.
My survey results are below, and I’ll unpack them a bit today.
Now the survey didn’t ask people any details about what these strategies look like, apart from the examples I listed, so I’m drawing on my experiences working with people living well with pain when I talk about them.
No surprises, movement practices come out on top. This is such a broad church of activities! In my PhD study, I found that movement practices were mainly woven into daily life. Things like walking or cycling to work, walking on the beach to ‘clear the mind’, taking the dog for a walk and meeting other like-minded pawrents, and yes… even going to the gym (some of you will know my aversion to that environment!). Movement practices are critical for people with pain because if we don’t maintain full movement practices, we tend to seize up, but more importantly, movement practices in my study were about having ‘head space.’
Movement practices are relatively easy to ‘prescribe’, to ‘count’, and to have unhelpful messaging around. Too many people are told they must do a particular form of movement practice, and do it in a particular way to ‘correct dysfunction.’ This means I’ve seen some people terrified to stop doing the exercises they were prescribed 15 years ago! Movement practices should, IMHO, be about relishing how amazing our bodies are. Celebrating the range of movements we can undertake, enjoying the different tempo’s and rhythms of our bodies, and that our bodies are the way we interact with our world. As long as we DO some movement practice every day, the kind of movement is really up to each individual. And if you use movement practices to ‘clear your mind’ – GO YOU! I do too!
Activity pacing is another familiar strategy, albeit weirdly difficult to define. I’ve defined it in my survey as ‘ways to keep your activity levels consistent‘ rather than the erratic ups and downs we can fall into when pain is the guide. Pacing does not mean you must take a five minute break every 20 minutes as I’ve often heard – pacing means you can reliably predict how much you can manage consistently whether it’s a good or a frankly rotten day. It’s the ‘do no more on good days, and do no less on bad days’ motto – tempered with the total enjoyment of doing more of a thing because it’s important (and fulfills something valuable to the soul), and less of a thing because we have planned to take it easy for that time.
Pacing is a skill that seems to need several steps to learn to use. There’s the initial phase where we need to establish just how much is ‘usual’ (we could call that the baseline); then there’s the adjustment phase where the focus is on adjusting activity levels to either increase or reduce the amount of activity to bring it to the level where it can be consistent; and finally there’s the living phase where it’s about being flexible and values-guided in choices about activity management. Now I’m making these stages up – they’re my observations having seen people at all stages of their living well with pain process – but what I’ve seen at pain management programmes (when pacing is introduced) is a lot of work on the adjustment phase and not much on the living phase. And so much of pacing seems to target ‘boom and bust’ or ‘increasing activity levels’ rather than the end goal which is to feel that we can be reliable about what we can expect from ourselves.
Managing sleep was the third most commonly used strategy and for this I am really happy! Sleep management wasn’t much on the radar when I developed the programme Springboard. While it was discussed a little, I don’t think we knew why sleep management is so critical. It’s because rotten sleep predicts greater pain the following day, and poorer sleep that night…. And having poor sleep poses a risk for developing chronic pain anyway. Pain doesn’t wake people up from sleep, but during those brief moments of wakefulness through the night, if we are experiencing pain, we’re more likely to notice it and wake more fully. If we can’t fall asleep easily, we can stay awake and feeling rotten.
Managing attention is another really important strategy – not to ‘ignore’ pain, or ‘distract from pain’ as much as to use attention to be aware of pain and the mind chatter that goes with it. We could call this ‘mindfulness’ but that brings with it a lot of unhelpful baggage, so I like to draw from ACT and call it ‘clean pain’ and ‘dirty pain’. Clean pain is all the sensory stuff – the prickling, aching, burning…. Dirty pain is all the commentary minds make about the clean pain, including a good few swear words! I suspect managing attention is something that gets easier with time but is inclined to fall apart when something else is happening in life. For example, when I’m not doing my movement practices, or when I’m coming down with a bug.
It’s important to recognise that attempting to ‘ignore’ or ‘not notice’ pain is impossible. Pain is an attention-grabber. Trying to NOT notice pain can be done but typically only for a short time and with much effort. What seems to be more useful is to notice and not judge pain negatively. I characterise my pain as like a very firm hug (at the moment, around my lower back and butt), or like tingly socks with toes in them (my feet are often sore at night). Imagery isn’t talked about very much but it is part of the ‘managing attention’ set of strategies.
I’ve just make a start on unpacking these strategies and as I do, I realise how little we know about HOW people use these during their daily life. When do people do movement practices? How long and how often, and do they change over a lifetime? What cues help people use pacing in their daily life? What happens if pacing can’t be used (eg if you work in retail, you know what I mean, right!)? How is attention management used when driving? When working in the office? When the kids are driving you nuts at dinner time?
The theory of these strategies might be buried beneath decades of cognitive and behavioural therapy and perhaps we haven’t truly examined them as they’re used in people not in a pain management programme. And maybe we haven’t even looked at whether what’s taught during pain management programmes actually transfers into living well with pain. And that is what I found in my study. Maybe it’s time to look a little more deeply into what people actually do in their world?
HealthSkills Blog 