Chronic pain

  1. Chronic pain is very different from acute pain and requires substantially different treatment.
  2. Chronic pain is influenced by a variety of physical, psychosocial and environmental factors.
  3. The cause of stable, chronic pain is less important than what is done to manage it.
  4. Regular physical activity is not only acceptable with chronic pain but is highly desirable.
  5. Hurt is rarely reflective of harm among individuals with chronic musculoskeletal pain.
  6. It is possible to have real and lasting control over chronic pain using the concepts contained in Gate Theory.
  7. The fewer aids and medications used to manage chronic pain the better, enhancing independence and self-control.
  8. Non-reinforcement of pain behaviors allows extinction of counterproductive habits to occur, paving the way for increasing appropriate life and work behaviors.
  9. Successful treatment of chronic pain needs to be interdisciplinary, progressive and integrated.
  10. Education about chronic pain and its long-term management adds to a sense of life control.
  11. Increased independence from healthcare providers enhances self-esteem, confidence, and sense of control.
  12. Successful long-term self-management of pain is characterized by minimizing flare-ups and maintaining activity levels during them.

#1: Chronic pain is very different from acute pain and requires substantially different treatment.

Explanation:
Acute (new) pain has signal value that stimulates corrective measures to stop damage, reduce discomfort, and allow healing/reactivation. Chronic (old) pain is pain that has persisted well beyond the expected recovery period and has no apparent signal value. Patients with very similar pathologies will have pain ranging from severe to none. The chronic pain sensation cannot be used to guide treatment reliably. Most treatments that are good for acute pain are counter-therapeutic for chronic pain.
Treatment Implications:
Factors other than tissue damage are important components of the chronic pain experience. They include but are not limited to genetic predisposition, development of central nervous system activity in utero and childhood, the chemistry of attitude/mood including overlapping and influencing systems in the brain, and muscle/joint disuse with sleep disturbance that can contribute to pain. It is important in treatment that the clients evaluate their more painful days to identify the variety of factors involved, i.e. activity and/or lack thereof, anxiety, stress, fear, etc.
Sample Situation:
A mangled arm needs amputation and is an appropriate situation for the use of opioid analgesics. A hand that is no longer attached to the body continues to hurt (phantom limb pain) but treating the pain as if the hand were there with opioid analgesics, for example, is illogical.
Typical Client Challenges:
It becomes necessary that the clients appreciate the concept that the part of the body that is hurting may no longer be in need of additional treatment. Handling flare-ups tends to be a very difficult challenge for clients. Finally, recognizing the difference between chronic pain, flare ups, and new injury is necessary for successful long-term coping. Most of us are raised in the traditional medical model that embraces the concept of diagnosis and cure and, not surprisingly, just want to be “fixed.”

#2: Chronic pain is influenced by a variety of physical, psychosocial and environmental factors.

Explanation:
A number of variables that influence the pain experience. Among others, they include stress, other medical problems, nutritional status, and social/cultural context. Pain is an experience. It is not a thing. Because it is an experience, it is potentially changed by everything that is going on in our life at that time and everything that has gone on in our lives in the past.
Treatment Implications:
The clients need help evaluating “pain days” and/or flare-ups. We can assist them in identifying the causes and influences over their symptoms including not only activity but also fear, anxiety, and/or negative self-talk.
Sample Situation:
Increased pain with stressful events provides the clients with evidence that a variety of factors, including physical events, can influence the overall experience of pain. Clients consistently report increases in pain surrounding holidays, the end of treatment at PRC, during medical emergencies, etc.
Typical Client Challenges:
It is the challenge of each client in treatment to realize that pain is not something to be killed, cut out, or cured. Clients also benefit from realizing that having chronic pain is not tantamount to having a psychological disorder. Many individuals with chronic pain are frequently involved in complex and confusing situations that include the workers compensation system. Medication addictions, depression, secondary gains and/or cultural factors also offer a number of challenges to each client.

#3: The history of chronic pain is less important than what is done to manage it.

Explanation:
Chronic musculoskeletal pain can be viewed as an entity unto itself and is not necessarily reflective of or a response to any new injury and/or damage. A specific, identifiable cause is rare. The searches for cause and effect relationships tend to be fruitless. It is frequently the case that the individuals are experiencing “tunnel vision” focused on the specific area and/or anatomical structure in chronic pain. This is frequently a nonproductive focus. Examining general changes that have happened biologically, psychosocially, and environmentally that are adding to and/or perpetuating the problem will usually prove more fruitful.
Treatment Implications:
Clients are frequently involved in pursuing an explanation for the presence of the pain. It is more beneficial and advantageous to encourage them to look forward rather than backward with regard to their pain. A good treatment protocol need not be custom tailored for the self-engrossed individual. The belief that no one has pain like mine only serves to perpetuate the misconception that the client is experiencing something that is not understood, unique, and/or undiagnosed.
Sample Situation:
Clients often spend time looking back at situations surrounding flare-ups. The focus at those moments is much more likely to be productive if it is forward. Stretching, ice, and positive self-talk are more likely to promote rapid return to activity than lengthy, passive reflection on the events leading up to a flare-up.
Typical Client Challenges:
Clients frequently believe that by identifying the cause of a specific flare-up, they will identify methods of preventing them in the future. They often want to be fixed in some definitive, discrete way. Furthermore, erroneous beliefs about diagnoses are common. There is also the pursuit of the “magic bullet”, i.e. someone in their life told them about a treatment, surgery and/or medication that cured or fixed someone. Clients tend to be best served by accepting the notion that their pain problems, as unique as it may seem, will be effectively addressed by essentially the same treatment protocol (normal) as everyone else with chronic pain.

#4: Regular physical activity is not only acceptable with chronic pain but is highly desirable.

Explanation:
The body’s design is such that an observer from Mars would identify it as an organic motion machine. Moreover, motion is the “on” signal for its homeostatic (self-sustaining/self-correcting) biochemistry. The body functions optimally during periods of appropriate activity, nutritional intake, and rest. Individuals with chronic pain share qualities and will nearly always benefit from activity.
Treatment Implications:
Muscles like motion. Motivation follows action. If you hurt you probably don’t want (aren’t motivated) to move but if you move you increase the likelihood you will want (be motivated) to move more and promote a higher level of wellness in your body. Reassurance that increases in pain are not indicative of damage facilitate this process. The most accessible point of entry into this cycle is via the clients’ decision-making powers. A willful decision to move is the starting point.
Sample Situation:
Last year I sprained my ankle so I can’t walk on it because it hurts versus I sprained my ankle so I have to start walking to stimulate normal strength, joint lubrication and eliminate the pain of disuse that has replaced the original pain this long after the original injury.
Typical Client Challenges:
The clients’ biggest challenge is to put fear aside; fear of pain, re-injury, and/or staff inexperience and/or incompetence. Furthermore, many clients have never been committed to exercise/wellness and will have to make major life changes if they are to successfully manage physical condition.

#5: Hurt is rarely reflective of harm among individuals with chronic musculoskeletal pain.

Explanation:
Harmful (tissue damaging) pain activates the autonomic nervous system in measurable ways, even in anesthetized individuals. Although the subjective experience of acute and chronic pain can be identical, people with chronic musculoskeletal pain show no autonomic arousal, i.e. the body is processing no harm messages.
Treatment Implications:
The primary goal of treatment is to increase activity and function. This increase has been demonstrated to reduce pain allowing further increases in function.
Sample Situation:
The evidence of the value of activity in the long-term management of pain of all types is plentiful, even among individuals with active disease processes. The PACE program of the Arthritis Foundation is built on the concept that people with pain can and should exercise.
Typical Client Challenges:
The clients’ challenge is to accept the idea that something that feels like the pain of damage does not signal damage. Fear of the possibility of re-injury is a significant barrier. Clients also benefit from accurately identifying “normal” muscle soreness that comes with increased activity.

#6: It is possible to have real and lasting control over chronic pain using the concept of Gate Control Theory.

Explanation:
The spinal cord has a number of biochemical systems that coordinate and regulate the flow of information between the peripheral nervous system (PNS) and the central nervous system (CNS). Gate Control Theory describes the system that controls the flow of pain information to the pain center in the brain at the spinal cord. “Long fibers” are a group of peripheral nerves that control the amount of pain signal getting onto the spinal cord “bus” to the brain. Heat, cold, pressure, etc. signals are processed by these long fibers. The “gate” controlled by the long fibers allows less pain information onto the bus when they are stimulated, i.e. ice applied to the painful area, etc.
Treatment Implications:
Gate Control Theory can be used as the centerpiece for the treatment of chronic pain. Mental distraction can serve as a very powerful adjunct to the process. The pain “system” can be rehabilitated just as the cardiovascular and/or respiratory systems can. Treatment also exploits the endorphin boosting system and neural activity stabilizing processes (activity, medications, etc.).
Sample Situation:
Hit your thumb with a hammer and see where your back pain goes!
Typical Client Challenges:
It is to the client’s benefit to see chronic pain as a system, not a specific part, that is not functioning correctly in the same way cardiac rehabilitation focuses on the cardio-vascular system, not just the heart. The gate concept is an invaluable way of taking advantage of known activities within that system.

#7: The fewer aids and medications used to manage chronic pain the better, enhancing independence and self-control.

Explanation:
Injury is an evolving process where one pathogenic mechanism produces others so that the cause of and therefore the treatment of the pain changes over time. Our bodies have hard-wired corrective mechanisms in place. The most effective and lasting wellness comes when those mechanisms are allowed to function optimally, e.g. without medications, etc. Furthermore, external interventions (surgeries, medications, braces, etc) frequently produce a set of secondary problems that further limit our innate corrective mechanisms.
Treatment Implications:
What is appropriate for acute pain (aids, medications, etc) is frequently disability enhancing for chronic pain. Aids can serve as badges of disability and/or inhibit normal corrective activities, i.e. canes, fiberglass back braces, etc.
Sample Situation:
Medication side effects, tolerance, and addiction are all reasons to limit their use. Compensatory movements regularly create new problems and/or exacerbate existing ones. A limb in a plaster cast (appropriate treatment for a fracture) undergoes wasting (and can develop CRPS Type II) but after healing is underway the cast must be removed to allow resumption of activity or the limb will be lost.
Typical Client Challenges:
It is difficult to abandon what has brought relief and comfort in the past (rest, passivity, etc). Medications and aids hold promise of relief. Re-mobilizing while having pain is counter-intuitive but essential. Potential challenges to facilitating the process include MD’s who over-prescribe the bad and ugly medications, anesthesia-based “pain clinics”, aggressive marketing by pharmaceutical companies, passive treatment enterprises (chiropractic, massage, acupuncture, etc.).

#8: Non-reinforcement of pain behaviors allows extinction of counterproductive habits to occur, paving the way for increasing appropriate life and work behaviors.

Explanation:
Operant conditioning principles state and have proven that any behavior followed in time by a reinforcer is more likely to occur in the future. Social, emotional, and/or physical reinforcement of expressions of pain (pain behaviors) increase the likelihood of the behavior occurring in the future. It happens either with or without the awareness of the client. Components of the pain behavior clusters are frequently compensatory actions (limp, etc.) that cause additional problems. Consistent non-reinforcement of pain behavior will result in a short-term increase in the frequency and/or intensity of the behavior followed by gradual extinction to zero.
Treatment Implications:
Non-reinforcement of pain behavior by staff and the accompanying rationale is discussed during orientation, along with instruction on what to do during times of increased pain (ask staff for help). The clients may perceive the absence of assisting responses and/or consolation for pain behavior as a lack of compassion and/or indifference. It is important that staff validate the pain but only when the behavior is not occurring. Ideally, all aspects of the client’s environment would be analyzed and reinforcers removed (home, work, store, etc.).
Sample Situation:
Significant others who do not attend PRC orientation and/or family meetings may inadvertently “undo” what is accomplished at PRC.
Typical Client Challenges:
The client will benefit from realizing that non-reinforcement of pain behavior is not the same as not caring about it and that doing so does not mean that PRC staff does not believe the pain is “real.” Cultural differences in the approach to pain may complicate the situation even further.

#9: Successful treatment of chronic pain needs to be interdisciplinary, progressive and integrated.

Explanation:
Scientific literature has thoroughly documented the advantage of interdisciplinary approaches to the treatment of chronic pain over single modality interventions. The complexity of the problem is so substantial that it is unrealistic to expect chronic pain to yield to a single treatment effort. Moreover, the coordinated actions of a skilled team produce a greater impact than the arithmetic sum of them. This synergy is likely responsible for much of the advantage pain clinics enjoy over other single modality treatments. It is not so with combinations of pain medications which generally produce “chemical soup.” Just because a person has had every component of the PRC program before admission does not mean that the treatment synergy cannot be effective. Setting goals reinforces progress and minimizes the negative impact of failures in daily activities.
Treatment Implications:
Clients can participate in variations on a complete program but at some point as components are removed its unique impact ceases to exist. Furthermore, there appears to be a minimum period of involvement before after which patients “get it.” Medicine, psychology, PT, OT, relaxation/biofeedback, and vocational counseling appear to be the essential ingredients.
Sample Situation:
A depressed, deactivated, unemployed client with 24/7 back pain about which he feels helpless and hopeless.
Typical Client Challenges:
Clients frequently don’t understand the necessity for each element of the program. To the extent that clients are able to allow each aspect of the program to be useful, They are more likely to succeed. Lack of support for the model/activities in the outside/post-discharge environment can severely undercut the durability of treatment results.

#10: Education about chronic pain and its long-term management adds to a sense of life control.

Explanation:
Chronic pain is rarely fixed or cured with one discreet intervention. Because it is a complex, long-term process not unlike diabetes, it is a condition to be understood and managed rather than fixed or cured. Education is the focal point for this approach. The education itself does not directly impact function and/or pain but serves as the foundation for making necessary behavioral/attitudinal changes. It provides the client with a road map for the journey. Progressive physical successes coupled with education allow the client to reclaim a sense of control over his/her body, pain, and life.
Treatment Implications:
Depression is prevalent among the majority of chronic pain clients. It is a typical response to significant losses. Loss of control over self and the world is a basic concept in several theories of depression. Coordinated physical rehabilitation accompanied by education/counseling can allow the clients to begin experiencing physical successes and rekindle the sense of control over their bodies and environments.
Sample Situation:
The disability conviction seen among many chronic pain clients is an expression of the frequent physical barriers with which clients are familiar. The “I can’t” mentality is built on repeated physical failures. Structured, small-step, progressive physical reactivation is the cornerstone of the effort allowing clients to reverse this process, regain a sense of control, and become less depressed.
Typical Client Challenges:
Fear of re-injury and lack of physical confidence are the two central physical issues among clients with chronic pain. Proof that the former can be reduced and the latter increased is central to progress in interdisciplinary rehabilitation.

#11: Increased independence from healthcare providers enhances self-esteem, confidence, and sense of control.

Explanation:
Many of the treatments with which clients have had experience prior to coming to PRC place them in the role of a passive participant. Clients describe the activities as being done to and/or for them. Furthermore, the perception that providers are the “givers of the cures” is typically actively and regularly promoted. The net impact of this situation combined with the losses experienced by the clients frequently leaves them feeling lowered self-esteem, confidence, and a sense of control. The self-management approach used by PRC in which the clients are given “tools” for self-management and encouraged to use them independently has benefits on a number of fronts.
Treatment Implications:
The education and physical “tools” given to clients must be understandable, relevant, and usable for them if treatment is to be successful. Common sense solutions, low-tech equipment, and a supportive, comfortable environment are a must among the clients with whom PRC works.
Sample Situation:
Clients frequently present themselves at PRC who are receiving ongoing, hands-on treatment of some type. The providers of these treatments do little to discourage long-term involvement with them. Although this type of situation provides some temporary relief, it does little or nothing to provide the client with long-term strategies for independence. The message is a clear one, “You have a special condition that only a trained professional can treat and you’ll need it indefinitely.” That is most often not the case.
Typical Client Challenges:
Clients are faced with a change in the way providers interact and help them. They must come to trust the process of self-management in lieu of other-management if they are to be successful in the PRC approach to treatment.

#12: Successful long-term self-management of pain is characterized by minimizing flare-ups and maintaining activity levels during them.

Explanation:
Many people work and manage their lives successfully despite pain levels similar to those described by pain program participants. The pain does not cause disability. Disability results from the inability to maintain activity levels when pain levels increase. Therefore, a goal of chronic pain management treatment is to teach methods of avoiding flare-ups that do not involve reduction of activities and teach ways of maintaining activity levels in spite of pain flare-ups.
Treatment Implications:
All program activities are explained in terms of how they help prevent pain flare-ups or help maintain activity levels during a flare up. The single most important day of her program may be the day one of the client’s pain levels is highest and pain is never a reason not to attend treatment. A clear distinction is made between everyday pain behaviors and inappropriate requests for assistance during a pain flare up. Once it is determined that a pain flare up is not an acute injury, the first question is, “how will you manage to do what is planned for today?” This is asked rather than, “How will you reduce your pain?” Participants are assisted in developing a plan for accomplishing scheduled activities. That plan includes effective and appropriate pain reduction techniques with the principal goal of maintaining involvement in treatment.
Sample Situation:
Reducing activities in response to pain is a natural and healthy reaction when the pain in question is acute and related to new tissue damage. For people with chronic pain, reduction of activity levels can actually compound the problem over time by causing physical deconditioning. People with chronic pain seem to be rewarded for reducing activities by and in deferred decrease in their pain associated with this change. They may or may not realize that the pain flare up likely would’ve run its course and pain would’ve returned to normal levels. Assisting clients and maintaining activity levels throughout a pain flare up allows them to understand that their level of pain and activity can and are unrelated to one another.
Typical Client Challenges:
Program participants reduce activity levels in response to pain for what are usually very good reasons. Maintaining activity levels in the face of pain is experienced as dangerous and counterintuitive. The pain naturally produces a fear response associated with the belief that if they continue they may hurt themselves. Only by maintaining activity levels through an entire flare up will they have the opportunity to discover that flare-ups are limited in time by their very nature and are generally independent of associated activities.

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