The Challenges of Chronic Pain
The Challenges of Chronic Pain
The challenge of managing and living with persistent (chronic) pain benefits from the understanding of the mechanism of pain (see the experience of chronic pain). Our understanding of pain has moved on greatly from the time when it was considered that if you had pain then some form of injured or damaged tissue must be present. Persistent pain is now considered to be a condition in its own right.
It is widely accepted in the medical/ health professions that management should be holistic, involving all aspects of the client’s life. A model of assessment and management is now used call the biopsychosocial model. This sounds very complex, but basically means that 3 aspects of the client should be considered:
a) Bio – biological: the physical body should be assessed for changes or injury,
b) Psycho – psychological: the aspects of anxiety and stress should be addressed,
c) Social – aspects of the social situation and home/ work environment should be considered.
These 3 aspects will have a bearing upon your pain experience. However it is not possible to decide how much each contributes to the pain. The exact mixture of the biological processes that are in action in any pain situation can only be a hypothesised (meaning an informed guess can be given).
The description of pain that you feel and other associated symptoms give some indication of the type of pain that you are experiencing. The variation in the pain either throughout the day or related to activity or medication and how the pain has developed over time (weeks or months) also gives some indication of type of pain that you are experiencing. This information can greatly help health professionals to consider all the possible processes which are contributing to your pain; the more information that you can give them the better. They may ask you to keep a pain diary, which will help in this process.
Team approach (choosing a team)
The most important person in managing your pain is you. It has been shown in clinical studies that the more you understand about the mechanisms of pain; the better you can control the pain. You know more about your pain than any health professional, you live with it every day. There are many health professionals that report that they can help you with pain. You will need some guidance, butchoose health professionals careful. They should all be able to consider the 3 aspects outlined above (bio-psycho-social), but will probably only be an expert in one field. Ask questions; find out how the treatment that they are proposing is going to help you, can they be sure it will reduce your pain? If you are well informed about pain mechanisms you may realise that you know more about pain than them! Be in control.
Some hospitals now offer pain management services. Usually this will involve a team of health professionals (doctors, physiotherapist, psychologist, social worker, etc). They will assess you and involve you in tackling your pain. They will advise you on the best course of action, this may be under the guidance of one of the team members, in a group situation, including education and graded physical activity or it may include input from the whole team. These types of services are best accessed through your GP, but they may vary from location to location.
Below is set out three areas of pain management that you will probably need to consider. All 3 may not be needed in every pain situation:
- Physical activity
Medication is only one part of the overall management strategy for chronic pain. Medications can be effective for some types of pain, but not all pain responds completely to medication alone, so physical and psychological methods of pain management should be combined with medication for the best effect.
Constant pain is best managed with regular medication to provide 24 hour control. A schedule of 4-6 hourly doses or the use of long acting medications will provide control over 24 hours. Taking medication regularly, usually results in better pain control using the lowest possible 24 hour doses, whereas waiting until the pain is very severe to take a tablet results in taking larger doses with poorer control over the 24 hours. Using medication according to this principle provides ‘background’ pain control.
Many people have chronic pain at a constant level throughout the day which can be satisfactorily managed with background pain control, however there will be times that the pain increases either due to physical activity, position (standing, walking, lying), or some other event. Whatever is the trigger, this ‘spike’ of pain is called ‘break through’ pain. At times of breakthrough pain there is the need to use medication which has rapid onset of action with short duration of action. Therefore it is best to have a combination of background medication and breakthrough medication.
Breakthrough medication can be used prior to activity that always results in pain to prevent it occurring. For instance if walking around a supermarket always results in increase in back pain, then taking a dose of breakthrough medication 15-30 minutes before going to the supermarket can prevent pain. In much the same way as an asthmatic will take medication before exercise to prevent the onset of asthma, medication can be used to prevent pain. Prevention is better than cure.
Education on how what the medication is used for, how to use it, and the side effects is very important. Make sure your Doctor tells you the reason for use of the medication, how it should be used and what side effects are possible and what to do if they occur. It is often best to have these instructions written down to prevent any misunderstanding.
Most analgesics have predictable side effects, and management of the side effects is essential. Some side effects may require the medication to be stopped, however side effects such as constipation can usually be managed satisfactorily to allow continued use of a helpful analgesic. Constipation should be predicted and prevented.
Our bodies are made for movement and movement gives the nervous system and the brain a lot of feedback about the body and the environment. It is background information, but it helps to normalise the nervous system. Movement also helps with many other systems of the body; it helps to keep the heart and lungs healthy, improve muscle and joint function and stimulates you mentally, to mention a few. Chemicals will also be released which reduce your sensitivity to pain.
It may be that the limitation to your physical ability due to pain is your major concern. Therefore, improving your activity so that the impact of pain is not so severe may need to be dealt with by a consultation with a physiotherapist. You may need to strengthen specific muscles or cut down the amount of activity that you do before taking a rest (this is called pacing).
Graded exercise routines; where people slowly increase the amount of general exercise they perform to re-condition their muscles, over weeks and months, have been shown to help people with persistent pain.
With people that are highly de-conditioned or fearful of movement these types of activities can be very difficult to perform due to aggravation of pain (pain flare- ups/ ‘break through’ pain) and hence need to be well controlled and monitored.
Ongoing pain can heighten emotional responses and it is common for people to experience increases in levels of: anxiety, irritability, frustration, depression, anger and guilt. Vicious cycles are created, whereby elevations in emotional states can also exacerbate pain. Pain can interfere with sleep, activity levels, roles and responsibilities, work, relationships, socialising, recreation and finances.
One of the most difficult challenges for people with persistent pain is to accept that the pain cannot be cured. Some people continue the search for many years in the hope they will find treatment to resolve their pain.
Medical professionals can help by providing information and an explanation of the bio-psychosocial nature of persistent pain. This information includes the changes and processes that can occur at the site of the initial injury, the involvement of the central nervous system, and the brain and other factors at the chemical, molecular and genetic level that can play a part in generating and maintaining pain. This often helps people understand why treatments at the site of the pain have been ineffective and can help them move towards adopting a broader pain management approach.
Frequently people with pain will be referred to psychologists or psychiatrists to help them to deal with their emotional responses and to learn strategies to cope and manage their pain more effectively. Some people may think this referral means the medical profession think their pain is imaginary, made up or that they are crazy. As a result they can often feel anxious and angry about the referral. Professionals taking time to provide feedback that the pain is accepted as real and explaining the bio-psychosocial model is important and can allow a shift in focus to management of the pain.
One of the important aspects of pain management is learning to behave and think differently about this condition and other aspects of life. This involves modifying or changing routines, responsibilities, the type, amount and way activities are undertaken and unhelpful thoughts and attitudes. These changes also impact on family and friends; people can struggle to deal with the changes. Information and psychological support of the family can be helpful in these situations. At times others may not be understanding or supportive and when this occurs there are psychological strategies people in pain can learn to help them cope more effectively with this experience.
In the early stages people often want change to happen quickly, however, attempts to do too much too soon can result in pain flare-ups. A more gradual systematic approach is required with small increments of activity. It therefore takes time, practise and patience for people to learn and effectively implement new strategies. Learning to deal effectively with flare-ups of pain is an important part of the management.
Embracing constructive change is an important aspect of pain management. For people whose identity or sense of self is connected to thinking and behaving in particular ways this can be a major challenge. They often fear that modifying how and what they do and think will result in them becoming a different person or loosing their particular identity. These types of thoughts often generate a great deal of anxiety and at times resistance to change. Allowing change to occur under these circumstances is therefore difficult. Reassurance, support and encouragement for people to explore the idea of change while retaining a sense of identity can be helpful.
In conclusion, persistent pain is a complex condition that impacts not only on those experiencing pain but family, friends and the wider community. There are approaches available that can help people learn to manage the condition more effectively. Evidence indicates that Cognitive Behavioural Therapy can provide strategies that help people manage not only the pain but other issues that accompany this condition. With determination and courage people can learn to manage the pain and get back to a more active life.
Remember above all that it is your pain; you know and live with it every day.
AMPA would like to thank Marcus Bowler, Barbara Workman, Pauline Gardner and Consultative Pain Clinic, Southern Health, for permission to reprint this information.