Persistent PainHealthshare Information for Guided Patient Management

Index

Introduction 2

How does pain work and what is the use? 2

Our perception: pain = damage? 3

Pain is one of the protective responses? 4

We change: Focus on Function? 4

Pain is multifactorial 5

Pain is poorly correlated with MRI’s, x-rays and imaging 5

Big take home message 6

The link between emotions and pain 6

From downward to upward spiral 7

Tips to turn the volume down 8

Healthshare comprehensive out-patient pain program (HCOPP) 9

Contact us 10

[ 1 ]

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Pain is anAlarm system- we can turnit down!!

IntroductionWe all have an experience with pain symptoms. It is a vital function of the nervous system, providing the motivationfor us to act and protect the body.

Sometimes these symptoms are minimal, but on some occasions, it could be unbearable. It is a very unique experienceto each individual and will not be same as your family and friends.

Our understanding about persistent pain has increased in recent years. This booklet will introduce some of the scientificfindings and will guide you in different ways to cope with symptoms and improve your functional ability.

How does pain work and what is the use?• Pain is like an alarm system that occurs when the brain perceives threat of damage to the body and wants us to

act.• The brain produces the pain. The message from the brain is weighed up by many aspects of your life experience,

immediate environment, personal or cultural beliefs, past injuries or your plan for the future. This process is all donevery quickly by the brain and then it reports to us to make the decision about pain.

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[ 2 ]

Our perception: Pain = Damage?

Pain is not a damage indicator. Hurt is not necessarily equal to harm.

• Acute pain is more associated with damage and it is usually short term.• If the pain persists for long duration, the link between the damage and the pain becomes weak.• The pain might not convey the right message about the location and it can happen even without ongoing damage

even though you may feel like it.• Persistent pain is less to do with the injury in our body and more to do with the brain and its nerve connections.

It is similar to a radio volume knob, which is turned up too high.

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[ 3 ]

Volume knobcould be changedat different levels

MinorInjury!

MajorInjury!!

The volume canchange here1The volume can

change here1

or here2

or here3

or here2

or here3

Image courtesy of the Tasmanian Health Organization South

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[ 4 ]

Pain is ONE of the protective responses. It may change many functions.• Pain changes our normal activities and body movement.• Pain changes our behavior. We learn to avoid things that may hurt. We start to do less.• Our muscle function changes: Decreases in strength, changes in balance and position sense, timing of muscle

action and reaction changes.• Our Immune system (responsible for defending ourselves), our endocrine system (controlling the chemicals of the

body) and our stress response( part of nervous system involving fight or flight or repair and digestion) might changewith pain.

PainMuscletension

Muscleinflammation

Reducedmovement

Reducedcirculation

We need change our focus away from pain, and to focus on increasing ourfunction and activity.

Image courtesy of the Calgary Pain Program of Alberta Health Services

Active CopingUsing Self-Management

Skills

IncreasedActivity

ImprovedSocial

Functioning

ImprovedMood

PhysicalReconditioning

Education &Pain Analgesia

FUNCTIONCENTERED

LIFE

PAINCENTERED

LIFE

Beliefs, Context,Past experience with

pain and anxiety

Tissue tension/Strain/Tightness

Injury/ Trauma

Family/Life style demands

Impaired Sleep-work-life balance/

Job/ relational difficulties

Way we think about pain

Avoiding the movement due to fear of pain

PAIN - MultifactorialPe

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[ 5 ]

Pain is multifactorial

• The brain interprets pain by processing information about many factors.• Different people have different amounts of pain even with similar injuries.• Pain varies from day to day because it is MULTIFACTORIAL.

We are NOT our MRI or X-Ray

• Pain is poorly correlated with x-rays, MRI and other scans.• Degeneration is like "wrinkles" on the tissues inside our body, similar to the face wrinkles, due to aging. Do we get

pain or ache from facial wrinkles?• The majority of people have disc degeneration from the age of 20 which peaks with age. The correlation with

degeneration on imaging is very poor with pain.• Some people without pain have “damage” on imaging.

but it still hurts

seems tohave healed

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[ 6 ]

Big take home message

• We need to change how we think about X-rays, Ultrasound and MRI’s.• We are NOT our MRI or X-ray.

The link between emotions and pain – Need to rethink and modify!!• Nerves act as electrical-chemical computers , sending messages up and down the body.• If the body is injured, chemicals are released which kick start messages in the nerves.• In sensitised (turned up system) nerves , chemicals released can ‘TURN UP’ the volume even more and increase our pain.

overwhelmedby life stress

poorsleep

scaredof pain

scaredof moving

sees friends& family

strongmuscles

manageslife stress

normalactivity &

movement

makesplans

bettersleep

‘volume high’ ‘volume low’

avoidingactivity &

friends

weakmuscles

run-downimmune system

Image courtesy of the Tasmanian Health Organization South

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[ 7 ]

Downward to upward spiral

• Multifactorial pain starts a vicious cycle, it can cause low mood and anxiety, which in turn increases the experienceof pain. Pain leads to movement avoidance, weakness, stiffness and tiredness, leading to further pain. There is nomore damage to the body, but due to the vicious cycle, pain and ability to cope gets worse.

• We can change and stop this cycle. When you acknowledge and accept this, we can turn the pain volume downand rediscover a full life ahead of us. It is a good first step to think about pacing activities that aggravate your pain. This can reduce the chance of flare ups.

• Stop thinking: ‘My body is damaged and needs fixing’ and change your thought process - regain control.• Gradually increase your activity, which will increase your confidence. Every small gain leads to positive changes.

moreconfident

startmoving understanding

your painmore

endurance

returningto normal

activity

feelstronger

and more in control

lessscared ofmoving

PAIN

painstarts

to reduce

Image courtesy of the Tasmanian Health Organization South

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Tips to turn the volume down

• Increase general activity

When we increase activity gradually we can reverse the negative cycle of inactivity and pain. When you do moreactivity, our body releases feel-good chemicals which improves the body and mind leading to increased confidence.

• Working towards personal goals

Start focussing on personal goals instead of on how to ‘fix’ the pain. When you work toward the goal, it may nottake the pain away, but can help to increase confidence and as a result, your enjoyment of life.

Set realistic and important goals, like walking to the local shops in two to three months, or finish washing thedishes without sitting down.

• Thinking differently about pain

Research shows that if you understand your pain more then you can control the pain and make better decisions,which will enable you to experience less pain. Relaxation can be a useful technique to help you manage your pain.

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[ 9 ]

Healthshare comprehensive out-patient pain program (HCOPP)

Our pain-clinic consists of multi-professional and highly experienced team which includes Pain Management Consultants,Specialist Psychologists and Clinical Specialist Physiotherapists.

At your first appointment in clinic, one of the specialists will assess you and recommend a management plan. Thisplan will be tailored according to your needs and health condition and will involve further appointments with otherspecialists in the pain clinic throughout. To prepare for this appointment, please download the pain-sense app andbegin recording your day to day activities, pain levels and any other information you think may be relevant.

Once you have been assessed the specialist will discuss with you an individual management plan, this may involve amedication review, injection therapy, physiotherapy or psychotherapy, this appointment is likely to take up to 60minutes

You will be expected to attend this appointment; as this is aimed at helping you to understand persistent pain, theimpact it can have and to introduce you to the practical strategies (which you can do) to minimise ongoing pain andreduce flare-ups between visits to clinic.

Pain Specialist PhysiotherapyPhysiotherapists assess and treat patients who have reduced mobility and/or physical de-conditioning due to persistentpain and can be involved at many different stages of the pain management pathway.

Depending on your assessment outcome our clinical specialist Physiotherapist will offer evidence based 1 to1interventions (Sensorimotor retraining, cognitive functional therapy and Cognitive behaviour therapy), or groupintervention (Pain management program - According to British Pain society guidelines).

Psychological therapyPain can cause distress and upset that has both physical and psychological (body and mind) features. It may be helpfulto look at both of these areas on a one to one level or through a group programme approach in the search for betterpain management.

Interventional treatments (nerve blocks)These are injections that are offered if your doctor decides that their benefit outweigh the risks. Most injections involvelocal anaesthetic and steroids to nerves, muscles or joints. You can prolong the benefit from any injection by adjustingyour activity afterward using the strategies learnt from the specialist nurses or physiotherapists. All interventionaltreatments are outpatient appointments at Ely day surgery unit. You will need to be accompanied by someone andhave transport arranged otherwise your treatment will be cancelled.

Once you have completed your individual course of treatment, you will then be referred to the Pain ManagementProgramme. This is a 6 week group programme to help improve your self-management skills and a chance to openlydiscuss how chronic pain has affected you with patients in the same position.

On completion of your treatment and the pain management programme you will now have all the tools and strategiesto manage your chronic pain independently of the service, however there are a number of community associationsdesign to assist patients with this long term support, information for which you will be given in due course.

Acknowledgements

• http://knowpain.co.uk/resources-2/persistent-pain-education-booklet/

• http://www.greglehman.ca/wp-content/uploads/2015/02/pain-science-patient-and-therapist-workbook-

january-2015.pdf

• Understanding persistent pain: How to turn down the volume on persistent pain. Tasmanian Health Organization

South.

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enquiry@healthshare.org.uk | http://healthshare.org.uk