1. How Pain Affects You
Pain affects your bodily sensations, behaviour, mood, thinking and life situation. What problems does your pain cause you? Mark on a line how much your pain controls you, rating the start of the line as 1 (least) and the end as 10 (most).
By compiling a list of problems, you can focus on what you really want to change. This can be done by filling in the following sections:
Bodily sensations: physiological symptoms (e.g. nausea).
Behaviour: your actions or lack of actions.
Thoughts: beliefs or rules.
Past/present life situation: work, relationships, finances etc.
From making the above problems list you can identify which are due to pain and decide on the difficulties you want to change. It may help to share the list with someone who can assist you to work through your list (e.g. a friend or GP).
Choose three areas, from the list, you really want to change and write these as targets in a notebook. Be realistic as it may be that only small changes are possible at present.
Note what you would like to change in your daily routine. What would be different if you had more control over your pain? What change do you want most (e.g. physical activities or enjoyable hobbies)? In attaining these changes would you spend more or less time with significant others? What will be better if you succeed with the desired changes?
In your notebook list the advantages and disadvantages of changing. Consider your most important reason for change and any concerns involved in making the change. Think about how you do manage and identify your strengths. Avoid comparing yourself to how you were before your pain. List what helps you to continue in resolving your problems.
Ask yourself how confident and prepared you are to change now and how important it is for you to change and attain the targets you identified earlier.
Build your confidence.
See Program 1: Coping Strategies Counselling Advice – Assertiveness Training, Neuro-Linguistic Programming (NLP), Building Confidence I, Building Confidence II, Building Confidence III, Building Confidence IV and Program 16: Overcoming Low Self-Esteem.
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2. Understanding Pain
How your pain makes you feel (e.g. worried, angry).
Describe the pain sensations (e.g. aching, sharp).
What are your thoughts about the pain (e.g. ‘My family is prone to headaches so I was bound to get them’)?
Has the way you do things changed or stopped?
Acute pain occurs with tissue damage and usually heals at six months. It is a mechanism to protect the body from immediate harm.
Chronic pain lasts for longer than three months and is not linked to tissue damage. It is due to a memory of pain in the nerves and resulting faulty pain messages to pain centres in the brain.
If you have a pain problem you should try to get around at your own pace and not lie in bed. Reduce some activities but not all, if the pain is bad. Increase activities gradually.
According to the Gate Control Theory of Pain (Ronald Melzack and Patrick Wall) there are ‘gates’ in the central nervous system which can allow or stop pain messages going through the pain system – negative thoughts open the gate and positive thoughts close the gate. Also, the body can make its own pain relief chemicals, endorphins which work like morphine. Endorphin levels increase with activity and help close the pain gate.
In chronic pain the gate cannot be kept closed all the time but it is possible to reduce the pain messages which get through the pain system. When the brain focuses on distracting activities the pain of injury is felt much less.
Note what closes the gate and stops the pain for you (e.g. distraction, physical activity, relaxation, pain relief drugs, anxiety/stress management, and increased knowledge of the pain system).
See Program 1: Coping Strategies Counselling Advice – Problem-Solving, Distraction Techniques, Controlled Breathing and Relaxation Techniques, Program 8: Overcoming Anxiety, Program 22: Overcoming Stress and Program 23: Overcoming Stress At Work.
List what opens the gate and causes pain (e.g. lack of activity, poor sleep, anxiety/anger).
See Program 1: Coping Strategies Counselling Advice – Nutrition, Exercise, Managing Your Time and Sleep Management.
After injury, muscles become tense and restrict movement. In chronic pain the pain does not reduce and the muscles stay very tense. These tissues may forget how to relax and remain stiff and tense. This can lead to areas close to the site of pain to also become pain areas thus, further limiting movement and seeming as if the pain is spreading. This is the vicious cycle of chronic pain.
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3. Investigating Pain
Blood tests can show the causes of some diseases but there is no blood test that shows the cause of chronic pain except for a disease called Ankylosing Spondylitis, which in rare cases, causes chronic pain and stiffness in the neck and back.
If a blood test is positive you may need further investigation (e.g. a CT scan). When the result of a test is negative it indicates that the illness tested for is not present. Currently blood tests cannot show the reasons for chronic pain. In most cases blood tests will not be required as the doctor will diagnose on the basis of your symptoms and a physical examination.
Your doctor may suggest an X-ray, a CT or an MRI. X-rays show fractures, dislocations and abnormally shaped bones and do not show soft tissues or pain. MRI and CT scans show the skin, bones, soft tissues and organs clearly but the latter has a risk of radiation. A positive MRI or CT scan can reveal damage to nerve fibres. If the result is negative it shows that your scanned body structure is normal, but gives no indication of what is causing your pain. You may be asked to have a bone scan if you are at risk of osteoporosis, inflammation or increased bone cell activity.
While waiting for the results keep yourself active, write down your worries and discuss them with your doctor and a good friend. Contacting a self-help group or PALS (Patient Advice and Liaison Service), may also be beneficial.
Physiotherapists know how the physical body functions but do not prescribe drugs. They can help you plan daily activities, solve problems, show you exercises to improve body movement and relaxation techniques to manage pain better.
Pain nurses can help you manage your pain better especially during setbacks. They can ensure you make effective use of pain relief drugs.
A pain specialist is normally a doctor who will investigate the causes of chronic pain and offer pain reducing treatment such as drugs.
Psychologists use different talking therapies to understand how the mind and body work. They do not prescribe drug treatment but can help chronic pain sufferers to understand how their thoughts, moods and behaviour are linked to their pain.
Psychiatrists can prescribe drug treatment and may refer you to talking therapy to support you as your condition improves.
Talking therapies (e.g. Cognitive Behaviour Therapy – CBT) can help you come to terms with your distress and give you the opportunity to discuss how your thoughts, mood, and life have changed due to chronic pain, and what changes to make to cope with the pain.
Pain management programs can help you cope better with life despite your chronic pain, and often involves working in a group with other pain sufferers to understand more about chronic pain. If you think it may help, ask your doctor to refer you to a pain management program.
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4. Making the Most of Medication
Medicines used to manage pain are: analgesics (including opioids), anti-inflammatories, anti-depressants and anti-convulsants. All these medications have side effects such as dependency, nausea, dizziness, constipation, dry mouth, blurred vision, poor concentration, and drowsiness.
Mild pain: non-opioid analgesics (e.g. paracetamol or anti-inflammatories such as ibuprofen).
Moderate pain: weak opioid drugs (e.g. co-codamol).
Severe pain: strong opioid drugs (e.g. morphine).
Analgesics and anti-inflammatories work well for acute pain to treat injury or inflammation but are often unhelpful to people with chronic pain. It is possible to become tolerant to a medication and thus require increased dosage for the same amount of pain reduction. If you misuse a medication you may become addicted to the drug. It is important to discuss with your doctor whether your medications will affect each other adversely and the possibility of an allergic reaction to any medication.
Make a list of all the medicines you use and mark on a line how beneficial they are to you with 1 at the start of the line as no pain relief and 10 at the end of the line as most pain relief.
Keep a diary for a week and note every three or four hours through the day and night, the date, time, situation, where you were, who you were with, what you were doing, your mood at the time and your thoughts. Rate your level of pain as 1 (no pain) or 10 (most pain ever). Note the dose and time of medication, and how effective your medicines are in relieving your pain - mark on a line the severity of your pain, from 1 at the start (pain free) to 10 at the end (worst pain ever).
Pain medications are more effective if you take them as soon as you detect the start of pain and this may allow you to continue with your daily routine with less pain.
Write in your diary the medications you take for pain; whether you take more tablets than prescribed to deal with your pain; what you do if the medications have no effect for two or three hours; whether you take tablets earlier than the next dose to deal with your pain; any distracting activities you use to deal with your pain.
It can be helpful to take the medication regularly and to match the level of pain to the medication strength. You may wish to reduce or stop taking your medicines. List the reasons for this (e.g. side effects, fear of addiction).
Earlier you marked on a line 1 to 10 how effective your medications are in relieving your pain. Take this into consideration if you wish to reduce or stop your medications. Write the pros and cons of continuing with your medications and list the side effects. Are you becoming tolerant to or dependent on the drugs? Do the drugs help you to sleep or in other ways?
If the disadvantages of continuing your medications outweigh the advantages you may wish to discuss reducing or stopping your medicines with a doctor. You can opt to gradually reduce your medicines and eventually stop – this is usually preferred. Or you can stop taking your pain medicines at once. Taking fewer medications will reduce the side effects and the pain can be managed by using skills such as relaxation and distraction.
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5. Goals and Rewards
Goal setting can make life more bearable despite the pain. You can set as required, time limits: immediate, short-term and long-term goals. You may need to break the goals down into small manageable steps. Tackle one step at a time, and prioritize the goal – planned activity or achievement. Use positive reinforcement for every little success to motivate you. Keep a list of your rewards. When it gets difficult rewards can help you to continue.
When you set a goal be specific; set a measurable goal so you know you have attained it; make sure you are capable of achieving the goal; ensure the goal is realistic; decide what the time limits are for the goal.
Write down three goals and decide whether the time limit is immediate, short-term or long-term. Note any skills or information you need to assist in your task. Ensure your goal is divided into smaller feasible tasks and plan on attaining these one by one gradually within the time limit. Consider activities that help you with realizing your goal and things that assist or prevent progress. What can you do about any barriers which block progress at present?
Keeping a list of successes can show you have progressed when you have a setback (e.g. pain is severe and you feel like giving up). Note what caused your setback.
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6. Pacing Styles
Pacing is a skill that helps you plan and monitor your activities so that you are in control of your pain. Your pacing style may be under or overactive, a mixture of the two or reasonable. List the advantages and disadvantages of your current pacing style. A helpful pacing style involves planning activities that are important and realistic and setting a steady pace with regular breaks. List the advantages and disadvantages of changing your pacing style.
Test if taking regular breaks or spreading the task over a longer time eases your pain and gives you more control.
Plan daily or weekly putting the most important activities first. Time each activity. Try not to be overactive on a good day and ensure you do some activity on a bad day. Gradually increase/decrease your level of activity. Involve others to help you with your plan, and reward yourself for any helpful changes.
See Program 1: Coping Strategies Counselling Advice – Planning an Activity Schedule.
Make a list of the activities you want to work on, putting the most important first. For each activity write the time it takes to complete it:
On a good day.
On a bad day.
Also, note realistically the time you think the activity will take every day despite your pain and the number of times a day you could repeat this activity. Steadily try to increase the time allocated to the everyday activities. Note any barriers to helpful pacing and how you could deal with them.
You need to expose yourself to a hierarchy of distressful situations to gain control of your fear/pain.
See Program 1: Coping Strategies Counselling Advice – Controlled Breathing and Relaxation Techniques, Eye Movement Technique (EMT), Mood Induction Procedure, Rational Emotive Imagery (REI), Imago Graded Exposure and In Vivo Graded Exposure.
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Perhaps you feel that others do not understand your pain or they do too much to help you. It may be hard for you to say ‘No’ or to request help and you may withdraw from social activities. Your pain can make you feel irritable and other people may feel rejected and be unable to cope with your distress. Try to talk through things to cope better.
See Program 6: Overcoming Anger and Program 12: Overcoming Depression.
At the start people can sympathize when you moan or withdraw to bed but in the long-term you need to involve them in your goals to manage pain. In this way they can support you in sticking to your plan.
You will feel more in control if you do things yourself at your own pace and ask others to help you in rewarding yourself for any positive action which will make you more likely to repeat it. In this way others can assist you with what you find really difficult and cannot manage alone.
Write down the following:
What is the most difficult thing about living with chronic pain?
How can I manage my pain better?
What makes it harder to manage my pain?
What can be done to help?
Discuss with loved ones what will help in managing your pain better. Sex may be avoided from lack of interest due to pain or because your partner fears causing you pain. Sexual activity can increase intimacy but many couples are content to live without sexual intercourse. It is necessary to discuss thoughts and worries with your partner so you both know how the other feels as this will make the connection between you stronger. Challenge any negative thoughts with your partner. It may help to set a time to try kissing and cuddling without pressure to continue to full sexual intercourse.
See Program 1: Coping Strategies Counselling Advice – Social Skills Training, Communication Training, Negotiation Training and Program 13: Overcoming Destructive Relationships.
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8. Troublesome Emotions and Acceptance
Your pain may be due to distorted thinking and perhaps you suffer from anxiety, depression and/or anger.
See Program 1: Coping Strategies Counselling Advice – Modifying Maladaptive Thinking and Troublesome Emotions.
Chronic pain can affect all aspects of a person’s life causing relationship, financial and emotional problems. The gap between reality and expectation can cause distress – the greater the gap, the more the distress experienced. To understand the gap consider what your life is like and who you are compared to what you expected to be and what you think and feel things should be like.
Acceptance can be defined as: ‘Experiencing events fully, just as they are and not as they ought to be’. It can also be seen as learning to live with the things you cannot change.
See Program 1: Coping Strategies Counselling Advice – Coping with the Need for Approval, Improving Your Self-Image and Combating Self-Harm, Criticism and Countering Self-Criticism.
Spiritual beliefs can be helpful.
Consider how chronic pain affects you, significant others and your future.
You need to come to terms with your losses; allow yourself to grieve and learn how to cope with the ‘present’.
See Program 1: Coping Strategies Counselling Advice – Forgiveness, Program 6: Overcoming Anger, Program 12: Overcoming Depression and Program 15: Overcoming Grief And Bereavement.
Make a list of benefits and opportunities you have or could have, since having chronic pain. Keeping these in mind can lessen your frustration and make you feel better.
See Program 1: Coping Strategies Counselling Advice –Competitiveness and Perfectionism, Frustration, Procrastination and Persistence.
Attentional Control or Mindfulness attempts to balance reasonable and emotional thinking with being wise (mindful). This can lessen distress and is similar to meditation.
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9. Managing Setbacks
Write out a plan for maintaining progress – include ideas such as:
Varying activities to avoid boredom.
Gradually increasing your activity level in enjoyable ways.
Monitoring your progress in a journal.
Setting realistic goals and rewarding you for effort.
Prioritize on what ‘could’ be done daily despite your pain.
Include pleasurable activities in your daily schedule.
Ask others to support you in your goals.
List factors which may block progress now or in the future such as lack of motivation or family circumstances. For each obstacle write a possible solution.
To deal effectively with setbacks consider what is likely to cause them (e.g. ill-health, family problems, worrying about debts). Divide the triggers into high-risk and low-risk factors. Note how you deal with a current setback so you can manage better in your next setback.
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Keep a positive data log to boost your confidence, to maintain progress or for when you have a setback. In the log note:
A statement that describes how you feel at present about managing your life despite pain.
Daily write one piece of evidence to support the statement that you are coping despite your pain.
Read your log daily to see the evidence that you can control your pain.
Rate your belief/credibility that you are able to manage your pain by marking on a line with 0% at the start and 100% at the end. Make a rating before you start the log and one month later to see if there is an increase in your belief levels.
You may be considering staying at work, finding a new job, or doing other activities such as volunteering or study. This can be enjoyable, give you a sense of purpose and build confidence. Consider the advantages and disadvantages of such goals and seek advice from job support services, occupational health services, human resources department and your supervisor.
See Program 1: Coping Strategies Counselling Advice – Relapse Prevention.
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