PERSISTENT PAIN:WHAT YOU CAN DO IN 10 MINUTES?

Richmond Stace MCSP MSc (Pain) BSc (Hons)Specialist Pain Physiotherapist

patient Low back pain Headaches Multiple joint pain IBS Anxiety & low mood

Picture the patient…..sitting in your office

First thoughts and feelings? Interested? Curious? Anxious? Frustrated? Excited? Worried?

Inner consultation What is your inner dialogue?

What are you telling yourself? What questions are you asking yourself?

Impact upon the consultation? Impact upon the person? Effect on next patient?

The problem of pain A systematic analysis for the Global

Burden of Disease (Vos et al. 2012) No. 2 -- back and neck pain No. 10 – migraine No. 11 – osteoarthritis No. 1 – depression

How many have pain & depression? How many people are in pain for all

reasons?

What is pain? Protection

A protective device A motivator Compels action Survival Adaptive To the person, it hurts

What if pain persists? Why in some people and not others? Why in this person?

What do they tell you in their story? What don’t they tell you?

Pain vulnerabilities Why is there on-going protection? Reasons why pain may persist:

Prior experiences of pain Kindling or priming Functional pain syndromes

E.g./ IBS, pelvic pain, migraine Existing sensitivity On-going stress/anxiety Genetics

The story Patient story

Needs validating We acknowledge their suffering with

compassion Needs meaning

How have they got to the present moment Nothing happens in isolation

Gives clues…

Here’s a story… Leg pain 18/12, worsening Incident => pain but no injury Previous leg pain Sensitive digestive system Insomniac

Has nothing to do with my pain I don’t have any stresses….

About to start IVF

Pain Pain is not an accurate indicator of tissue

damage It is the person who experiences pain,

not the body part Shift in sense of self Pain is a response to a perceived threat Pain is experienced in a ‘space’ What is threatening?

A movement, an action, a thought?

What I am feeling now… Is the brain’s best guess Selection of a hypothesis What does all this sensory information

infer? What does it infer based on what I know? What does it infer based on what has

happened before? Pain, pain, pain, pain, pain…. A prediction

The person Beliefs Expectations Thoughts Movements & posturing Role in life: work, home Lifestyle patterns Ever changing….adapting…learning

The person in pain How do they change?

Body sense Movement Planning Thinking Emotions Perception Self

What story are they telling themselves? The story of their pain Cause and effect I must avoid…. I can’t….

All consuming Pain can pervade into all aspects of

existence Feeling Thinking Sensing

The lived experience Moment by moment

Biology of pain? Where is it?

Whole person Many body systems that protect Most of it is not where the pain is lived

A thought about the pain is biology ‘Biology in the dark’

Where is the pain coming from?

What influences pain? The way we think about it; the meaning to

‘me’ Beliefs about pain Attentional bias – vigilance to body Stress (threat) Tiredness – more sensitive, less resilient Context Environment Prior experience

Stress and pain Pain is a stressor Chronic stress => more inflamed Situation => perception/meaning =>

response Prepared for/reacting to perceived threat

Systems ready Systems dampened: GI, reproductive

Think of a time… ….when you were feeling stressed How do you feel now? Where did you feel it? What did you feel it with? Your mind -- where is your mind? Embodied cognition

No separation of body-brain-mind-environment

‘Whole person’

Sleep and pain Sleep problems appear to predict onset

of chronic pain Predict persistency and increase in pain

levels Effect of pain on sleep less strong We need sleep! And a good period of

sleep

Improving sleep Calm conditions before bed

Bath, mindfulness, reading Associate bed with sleep Unhelpful thoughts – mindful practice Lifestyle patterns

Eating time Refresh and renew through the day

Pause

Functional pain syndromes IBS Migraine Pelvic pain

Dysmenorrhoea vulvodynia

Fibromyalgia Often with:

Anxiety Hypermobility

Functional Pain Syndromes (2) Vulnerable to persisting pain

Common adaptations underpinning all Protection Perception of threat: cues & triggers widen

Great example of need to tackle whole person

Getting better What is getting better? Who gets better? I am better The person gets better Who do we treat?

Who gets better? Those who understand their pain Those who use their working knowledge of

pain Those who use their strengths Those who persevere Those who focus on an outcome not the pain Those who see the flare-up as a challenge to

overcome Those who deal with distractions

What does an approach need? To be a lived experience Be available moment to moment Promote independence A focus on the outcome For the ‘action’ to change the prediction At any given moment

Pain Coach Coaching the person to become their own

coach What do I think? What do I do? Create the conditions for the desired outcome Outcome focused – their vision of healthy self A blend of pain neuroscience and strengths

based coaching Getting the best out of a person Maximising their potential

The early messages Set the scene Need to be accurate Need to answer:

What is wrong? What do I need to do? What will you (clinician) do? How long will it take?

Mature Organism Model

10 minutes to…. Listen Work out what is happening Explain Make a plan Take some action Patient’s perception of the consultation?

Their reality

How long does it take for pain to change? Pain – No pain On – off Pain is not constant Each moment is new Each moment is an opportunity You cannot not change!

The potency of you…know that… Behind your words

Knowledge Insight Understanding

A trusted advisor, a coach You are a ‘drug’ affecting their physiology

Compassion Approach Words of advice

Understand pain Understand pain to change pain – explain it

What is pain? What is their pain about? Specific to them and their story Creates a foundation to start reducing threat Working knowledge: what do I think? What do I

do? Independence, control, empowered

Pain is about perceived threat Reduce the threat = reduce pain

UP | Understand Pain

@upandsing understandpain.

com

Actions (1) Referral

Reasons explained Investigation(s)

Reasons explained Lifestyle advice

Reasons explained Influencing pain; e.g. sleep pattern, stress

Actions (2) Further information

Quality reading material, website Medication

Reasons and explanation of how it works Expectations primed

Foundation of understanding that creates ‘safety’, confidence and motivation

Changing their perception/relationship with pain

For you: keeping your clarity Focused attention (mindfulness) Breathing between patients Movement between patients Greeting style as a way to shape session Actions emerge from clear thinking,

engagement & compassion

The person needs to… Understand their pain Understand what influences their pain Understand what they can and must do Understand that their pain can and does

change Show them and give examples

Focus on their desired outcome Know they are believed and supported

Pain Coach Coaching the person to be

their own coach Realise their independence Moment to moment decisions Moment to moment actions Pointed towards desired

outcome Optimising potential Resume a meaningful life I feel like ‘me’ again

And relax

Thank you

www.understandpain.com www.specialistpainphysio.c

om @painphysio @upandsing painphysiolondon@gmail.co

m