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hronic or persistent pain is any type of pain that lasts more than three months.1 Persistent pain lasts longer than acute pain and Coften does not indicate ongoing damage. In the past, we assumed that this was because the injury had not healed, but we now know that for most people this is unlikely. Instead, the pain is less to do with injury in their bodies and more to do with our central nervous system.2
To successfully manage persistent pain requires a holistic approach from both patients and healthcare professionals. It is an ongoing process where we look at things like stress, behaviour, mood, emotions and how people cope with their pain on a day-to-day basis.3
Pain management programmes
“Persistent pain is a whole life problem, so effective management needs to take a whole-life approach,” says Orla Spencer, Clinical Psychologist in the Pain Service in Tallaght Hospital. A Pain Management Programme is a rehabilitative treatment for people with chronic pain that is delivered in a group setting by an interdisciplinary team of experienced healthcare professionals working closely with patients. “For the majority of people, attending a Pain Management Programme reduces the disability and distress caused by persistent pain by teaching physical, psychological and practical techniques to improve quality of life,” continued Spencer.
“Pain can lower mood and low mood can increase experiences of pain — leading to people avoiding exercise and activity, which in turn causes weakness, stiffness and tiredness — which may increase pain,” says Spencer. “But once people understand and accept this, there are a lot of things they can do to reduce their pain and improve their quality of life.”
Conversation starts with the GP
“Spaces are limited on these pain programmes but the conversation on how to manage pain starts with the GP. This will often include advice on taking medication and the importance of pacing activities and setting goals. Also, help with finding an exercise programme or referral to a chartered physiotherapist,” says Joanne O’Brien, Registered Advanced Nurse Practitioner in Pain Management (RANP) in Beaumont Hospital. “In Beaumont, we run an early intervention multidisciplinary pain workshop for new patients referred into our service. Following these workshops, patients have said that they understand their pain a little more and have a better understanding of what they need to do to manage it, whether it’s exercise, losing weight or keeping mobile without the worry of further injury. Some patients who have attended the workshop have been able to return to work, so the benefits of increasing patient knowledge and self-management may bring improved patient outcomes.”
“Pain management programmes allow people to take control back. In our clinic, we help people to understand their pain so they can learn how to pace their activities and set realistic goals. Under the guidance of a GP or practice nurse, these techniques can be rolled out in the primary care setting,” says Spencer.
“When a patient comes into our clinic, we ask them a range of questions to help us understand their pain and to develop the appropriate treatment plan. Some of the main questions we ask are: What makes your pain better? What makes it worse? Where does your pain radiate to (down your leg, arm etc)? On a scale of 0-10, how would you rate your pain (0 = no pain and 10 = the worst pain ever)? What type of pain is it (dull, sharp, hot, cold, numb, pins and needles, etc)? Patients’ own descriptive terms can help us to classify what type of pain they have — nociceptive, neuropathic or a mixture of both,” says O’Brien.
To help people explain their pain and receive an accurate diagnosis and treatment, the ‘mypainfeelslike…’ campaign has developed the ‘mypainfeelslike…’ pain questionnaire, available at mypainfeelslike.ie. The campaign has also developed a series of images with American-based artist David Schwen, that visually interpret pain symptoms such as burning, stabbing and crawling under the skin.
Encouraging active participation in pain management
Self-management aims to improve a patients’ health and wellbeing by managing the impact pain has on their life. Encouraging patients to engage in an active management plan may help reduce pain symptoms, improve mood and increase function.3
“One of the recurrent issues we have with patients revolves around not taking their pain medication regularly,” says O’Brien. “Many people take pain medication one day, feel better and then stop taking it. Or they only take it when the pain is very bad and find that the mild pain medications they have been prescribed are not sufficient to cover this increased pain. As part of our workshop and of every consultation, we explain to patients the benefit of taking mild pain medication regularly to prevent pain from building. We also encourage people to start a daily journal in order to monitor their pain, their response to pain medication and also how their pain reacts to different activities,” continued O’Brien.
When asked about making patients active participants in pain management, Orla Spencer says, “we work with patients to show them how to pace their activities so they’re never doing too much and taking breaks before they need them throughout the day. It’s about making everything more manageable and understanding that they can’t do the same level of activity on bad days as on good days. This will help to avoid the under-activity/over-activity cycle.”
“From the beginning, we ask people to set daily, weekly and monthly goals and targets that allow them to decide what they want to achieve — it gives them something to focus on and aim for, helping them to gain control of their life and making them feel better mentally and physically. Goals allow people to move forward,” says Spencer.
Setting short-term and long-term goals with patients:
• Short term: Walking one mile in four weeks’ time.
• Long term: Walking a mini marathon with friends in six months.
Current research recommends that maintaining regular exercise is important when someone has persistent pain. “Many people attending our clinic are afraid of exercise, as they think it will do damage. Our team includes a specialist physiotherapist, who works with patients to help them find exercises that will help them manage their pain and build up strength and confidence,” says O’Brien. When asked about what activities patients can do, O’Brien said that they suggest activities like “pilates (especially for back pain), walking, cycling and aqua aerobics.
“We encourage people with pain to talk to their chartered physiotherapist about an exercise plan and to develop a personalised stretching and exercise programme that they can work on slowly and safely.”
The practice of mindfulness or meditation can help people manage pain and the stress that comes with persistent pain.4 “Studies show that mindfulness can make changes in the brain and the avoidance strategies, like not going out when asked, are reduced.
“The aim is to adopt approach strategies that help patients break down the task and solve the problem”, says Spencer. “When patients manage their thinking, they can learn to accept their pain and find different paths to improve their quality of life.”
Pathways through pain multimedia guide is now available on mypainfeelslike.ie and includes practical information to help people manage their pain, videos with Joanne O’Brien and Susan Murphy, Clinical Physiotherapist, University Hospital Waterford, a mindfulness practice podcast with Orla Spencer and a pain management rehabilitation conversation with a patient who attended the programme in Tallaght Hospital in 2016.
Brevik et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10:287–333.
Understanding persistent pain. How to turn down the volume on persistent pain. Department of Health and Human Services. Tasmania.
Bussing et al. Adaptive coping strategies in patients with chronic pain conditions and their interpretation of disease. http://bmcpublichealth. biomedcentral.com/.articles/10.1186/1471-2458-10-507.
http://www.stillmotion.net.au/mindfulness_programs_Sal_Flynn.html. Last accessed June 2016.
Date of preparation: November 2016, IRE/MPF16 0013a