Coping Skills

Pain Management Skills Survey

Something we don’t know very much about is the way health professionals view the type of coping skills that are often recommended for patients.
This survey is one way to start to learn more about what you as a health professional think about some of the coping skills commonly used in pain management.
It’s completely confidential, very quick to complete, and I promise it has absolutely no nutritional value!

Click on this link and I promise it’ll be painless…

And in a couple of months, when I reach my target number of participants, I’ll post the results!

thanks heaps for doing this!

Self efficacy for returning to work

Of the two dimensions I usually assess with people not working because of chronic pain, lack of importance given to returning to work is often identified by ‘onlookers’ as the main reason someone hasn’t yet returned. I don’t know how many times I’ve heard about ‘secondary gain’ getting in the way of people making progress – and yet when I look in to research into returning to work, it’s self efficacy, or confidence to successfully return to work, that has more press than any other aspect (oh, apart from physical ability vs job demands).

I’ve blogged about self efficacy several times now because it seems to be one of those factors that pops up all over the place – as Bandura himself puts it ‘Self-efficacy beliefs determine how people feel, think, motivate themselves and behave.’

I mainly look at self efficacy in terms of confidence to achieve a desired result. When I’m looking at the process of returning to work with someone, the two facets I review first-off are importance and confidence. Using the Prochaska and DiClemente transtheoretical model, both of these elements can be used to determine the stage that someone might be in terms of their readiness to take action.

Let me unpack that a little. If you recall the stages of change model, there are several stages before someone is ready to actually do something to achieve a goal. At these pre-action stages (Precontemplation, Contemplation, and Preparation), people have yet to decide whether action is the right thing to do, let alone work out how to do it.

At the Precontemplation stage, action is nowhere on the scene.
At both Contemplation and Preparation, the person is often ambivalent and maybe not yet ready to even learn what to do.

To help people work out whether they want to take action, it’s worth exploring these questions:
(1) Have they thought about returning to work at all? (Precontemplation)
(2) How important is returning to work at this stage in the person’s rehabilitation? (Contemplation)
(3) How confident is the person about actually returning to work at this point? (Contemplation)
(4) If importance is high, but confidence is not, what things are concerning the person about returning to work? (Factors that influence Preparation)

A study by Shaw & Huang (2005) showed that the areas that people are concerned about (ie, the things that reduce confidence) are divided into two main areas –

  • concern about resuming physical activity, and
  • concerns about resuming work.

The concerns about resuming work were divided into three main areas –

  • meeting job demands,
  • obtaining help, and
  • coping with pain.

In fact, out of 348 statements that were coded in this study, 253 were about self efficacy, while the remaining 95 were expectations about returning to work. Expectations were around financial security, re-injury, workplace support and self-image.

So, some of the areas that may be contributing to low confidence for returning to work may be:
– can I do what I have been employed to do at work?
– can I do these tasks to the standard that my employer wants?
– can I do them as well as I want to?
– can I be reliable at work?
– can I (or do I want to) ask for, and get, help?
– can I change the physical environment at work so I can do the job?
– can I cope with the pain?
– can I prevent the pain from taking over?
– can I avoid injuring myself?

This list isn’t exhaustive, but based on Shaw & Huang’s work, covers many of the factors that people think about when they are concerned about going back to work.

Once the areas of low confidence, or concern, are identified, our job is about helping people develop confidence in those areas.

Often it is simply problem-solving ways around their concerns. Things like ensuring there is a clear description of the task demands (especially during any work trial or gradual return to work), clarifying quality requirements, ensuring reporting lines are clear, and arranging for physical environment alterations and any adaptive equipment to be available from the outset.

Other times it’s much more difficult – especially where there is a mismatch between what the client has been able to achieve in the past and what he or she can do now (this especially holds for people who push themselves to achieve well, or previously worked at 110% and now can ‘only’ manage 98%).

This may mean working through some cognitive therapy to reframe or challenge automatic thoughts, (eg ‘I’m working at this level because it’s part of my rehabilitation’ rather than ‘I must always work incredibly hard’, or ‘Most people work at 90%, and that’s all I need to achieve’, or ‘It’s OK to work at 90%, it means I can keep going for longer and be reliable the next day’).

The process of building confidence through cognitive therapy can be very challenging, especially if the person hasn’t had any exposure to CBT during their pain management rehabilitation. In fact, I often find that people may have had some CBT-based pain management, but until they reach the work environment, the real objections or core beliefs haven’t been explored, and the real ‘work’ of cognitive therapy begins only once those objections are raised.

Shaw, W., Huang, Y. (2005). Concerns and expectations about returning to work with low back pain: Identifying themes from focus groups and semi-structured interviews. Disability & Rehabilitation, 27(21), 1269-1281. DOI: 10.1080/09638280500076269

Pain Management Skills Questionnaire

There are lots of coping skills out there in pain management land – but we don’t always agree on what they are, when they need to be used, or even on how important they are in the overall scheme of things. I’ve developed a brief (anonymous and confidential) questionnaire about different coping strategies – it will take between 8 – 13 minutes (really!! I tried it myself! – well, OK, I’m just guessing), and I would be very grateful if you’d consider participating. I can’t obtain any details about you, your computer or anything personally revealing through the questionnaire. I’ll publish the results once sufficient responses have been made, so get clicking!!

Click Here to take survey

Thanks so much for participating!

If you find it hard to slow down…

Self regulation is something we learn to do to achieve goals – it’s all about establishing what the goal is, find out how close we are to the goal, the gap between where we are and where we want to be, and what we need to do to get there. This is a reasonably good overview of the concept, although related to sports goals, but worth a read.

In pain management, self regulation includes working out how much physiological arousal is needed to achieve activities – and how to settle that arousal level down as required. For many people with pain, their physiology becomes over-aroused in response to pain (or as part of the development of the chronic pain condition), while others find it difficult to increase their level of arousal sufficiently to be able to engage in activity. This is a simple explanation of some of the concepts of physiological arousal, in relation to ‘stress’.

We often teach strategies such as relaxation (this is a helpful book) and diaphragmatic breathing to people, but I find that those who are ‘pushers’ (over-active) as compared to those who are ‘busters’ (under-active) can have difficulty using traditional methods to s l o w d o w n…

Another option, and one that has been used for thousands of years by religious orders of many persuasions is a ‘walking meditation’. Many monastery gardens as well as buddhist gardens were formed to enable the monks to walk in quiet meditation. And I don’t know how many nights parents have spent walking the floors with babies, rocking them to sleep! So it’s certainly something that has stood the test of time!

How do you do it?
Well the basis of a walking meditation is to spend time without distractions being fully aware of the body, the ground, the environment while walking at a steady pace. The length of time isn’t as important as the open awareness of the mind while doing it.
For those who perhaps haven’t spent time in meditation before, here is a simple set of ‘instructions’ that you can use for yourself or for a client, to start the process of a walking meditation. If you’re going to introduce this to a client, you’re best to do it with him or her the first few times, using your voice to guide the attention.

In one way this practice is simpler than the sitting meditation – but in other ways it’s more complex — simply because there is a lot you can be aware of while doing walking meditation. It doesn’t matter where you do this – in a busy place, a quiet place, level ground, uneven ground – but to begin with, try to find somewhere quiet, and on even ground so you have a little less to think of.

So, to start of this meditation, first of just stand still. Become aware of your weight through the soles of your feet into the ground. Become aware of the constant small movements that keep you balanced and standing upright. Notice your weight through each foot, through your knees, your hips. Notice your buttocks, your abdomen and how your arms all work together to hold you upright.

Then start to walk, at a steady pace, not hurrying, just stepping left foot, right foot, one after the other. Notice the soles of your feet, being aware of the alternating patterns of contact and release; being aware of your foot as the heel first makes contact, as your foot rolls forward onto the ball, and then lifts and travels through the air. Notice the way your toes touch each other, the fabric of your socks and shoes, or if you’re barefoot, the texture of the path. And notice how your ankle bends and the way your lower legs tense and release with each step.

You can become aware of your lower legs – your shins, your calves. You can be aware of the contact with your clothing: be aware of the temperature on your skin; you can be aware of the muscles. The movement at your knees, the bending, the stretching. The thighs tensing and releasing with each step, and the way the hips move. Your pelvis, the rise and fall as you take each step.

And you can be aware of the complex movements that your pelvis is carving out through space as you walk forwards. The lowest part of your spine – your sacrum – is embedded in the pelvis. So as you feel your spine extending upwards – the lumbar spine, the thoracic spine – you can notice how it moves along with the pelvis. Your spine is in constant motion. It’s swaying from side to side. There is a twisting motion around the central axis. Your spine is in constant, sinuous, sensuous motion.

Notice your belly – you might feel your clothing in contact with your belly – and notice how your belly is the center of your body. Very often it feels like it’s “down there” because we are so much in our heads. Notice how your abdominal muscles move with each step. And the movement of your chest as you breath in and out – be aware of how long each breath takes, how many steps it takes to breathe in, how many to breathe out.

And be aware of your shoulders and your arms as they move to counter the steps you take, and how you bend at the elbow and how you hold your hands.

Become aware of your neck – and the muscles supporting your skull. Notice the angle of your head. And notice that as you relax the muscles on the back of your neck, your chin slightly tucks in and your skull comes to a point of balance. Relax your jaw. Relax your eyes — and just let your eyes be softly focused, gently looking ahead – not staring at anything, not allowing yourself to be caught up in anything that’s going past you.

Then while you’re still walking, notice the sounds you can hear, the sights and the smells. Notice the wind and the sun, the temperature – and breathe in, breathe out as you walk for as long as you need or want.

When you’re ready to stop, don’t return to normal life too quickly. Spend a moment or two standing still and allowing yourself to enjoy the moment.

As for any meditation, if you notice your thoughts straying way from experiencing the sensations, perhaps naming feelings, planning a meal, pondering a problem – gently bring your mind back to your breath.

I hope this is helpful to you and your clients.  While this specific meditation hasn’t, as far as I know, been researched in terms of pain management, the benefits of meditation have been well-established.  If you’ve enjoyed reading this, and would like more (or perhaps something different!), you can subscribe through the RSS feed (above left), or bookmark the blog so you can find it again!  And do feel free to comment and let me know what you think.

Motivating people to make changes (i)

The first of a series about using values and empathy to help people make choices

Most of our training in health care provision assumes that:

  • the people we will be working with are ready to receive our knowledge/expertise
  • we know more than they do (about what they should do)
  • their health status is the most important thing in their lives (well, we think health is important, don’t we?)
  • all they need is for us to tell them what to do and they will go away and just do it

And if they don’t – they’re ‘resistant’, ‘not motivated’, ‘noncompliant’, ‘nonadherent’.

– and we’ve always known how they show us this!!

They may

  • say ‘yes but’ to any suggestions
  • become silent
  • become angry
  • deny they have a problem
  • interrupt
  • avoid making a commitment
  • not come back to see you
  • pretend they are doing what you suggest, but actually do nothing

By taking care to really understand the good things about the way the person is currently acting, and the not so good things about changing, we can work together to help change occur out of intrinsic motivation, or values that the person holds.

Read on…!

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