Self-Management of chronic pain:
Information for practitioners

If pain from an injury does not resolve within 4-6 months, a cycle of chronic pain can develop. Once a chronic pain cycle is established, a purely physical treatment regime rarely resolves the problem. Chronic pain has an impact on the person, their family and their lifestyle. Unless all these factors are addressed, the situation frequently deteriorates and pain persists. Self-management skills can prevent development of chronic pain, and provide skills for self-help and self-healing in more established cases.

Suitability for the Program
Self-Management/Pain-Management programs are frequently seen as a last resort but early referral can prevent the development of chronic pain syndromes and the inevitable suffering for the person in pain. Many participants in self-management programs express regret about not being referred earlier. Part 1 of the Path out of Pain course may be sufficient for someone whose situation is uncomplicated, and it enables them to take an active part in the management of their condition soon after the injury or onset of pain. For those who have more established pain syndromes, it is advisable to do Part 1 and Part 2. You can read more about the “Path out of Pain” course in Workshops.

Early Referral is recommended for:
1. People not responding sufficiently to physical treatment;
2. People who have become anxious and/or depressed about their pain/injury;
3. People who have not returned to work by 4-6 months;
4. People experiencing coping difficulties.

What is Pain Management?
The approach is two fold:
1. Direct pain reduction with skills for reducing pain directly or reducing the amount the pain bothers the person.
2. Indirect pain reduction: To help restore a normal lifestyle by increasing activity levels,

• resolving conflicts and grief,
• overcoming fears,
• education about pain,
• providing support and encouragement,
• learning self-management skills,
• and developing positive attitudes.

Restoring a more normal lifestyle reduces pain and/or its impact on the person.

What is Self-Management?
The aim of self-management is to teach skills for self-help and self-healing. It can be complementary to other forms of treatment but the long-term goal is to minimize the need for passive therapies. However, one of the dangers of several practitioners being involved, is that the person receives conflicting advice. This is when good liaison between treating practitioners is essential so that differences in approaches can be identified and resolved. Self-Management helps restore a sense of control for the person in pain, and it is important that all the treating practitioners support this objective.

The Program
Two keys to success with Relaxation are daily practise, and finding the right approach for each person. A range of techniques are taught to assist with finding the best method/s.

Many people with chronic pain are reluctant to Exercise because it hurts. Whilst there can be contra-indications to certain exercises, an increase in fitness, strength and mobility is essential for a return to a normal lifestyle. Our approach is to start very gently, building confidence with exercises designed to give relaxation through movement. Participants are also encouraged to start getting fit with a walking program.

Appropriate Attitudes are fundamental to recovery. Through talks, discussion, and videotapes participants are introduced to a wholistic approach to management. We believe that their condition is not just physical, nor psychological, but something which affects them as a whole person and can only be managed effectively by looking at the whole person: not just the injury/condition. A belief in the possibility of recovery or improvement is fundamental. This belief has often been shaken or lost in those who have been in pain for a long time. Because pain is modulated by psychological factors, there is always an opportunity for improvement.

A return to a meaningful Occupation can be the turning point in a person's recovery. Loss of direction and purpose in life is a recipe for persistent pain and disability. We encourage a return to work as early as possible to prevent a chronic pain cycle developing or, to facilitate recovery from chronic pain. Both increased self-esteem and job satisfaction can be powerful healing forces.

Goals of the Program (for participants)

• To develop a belief in recovery/improvement and their capacity to achieve it;
• To increase self responsibility and sense of control;
• To adopt a more relaxed approach to life and learn to relax physically
  and mentally;
• To reduce pain levels and/or the amount it bothers the person;
• To increase activity levels and function;
• To better understand chronic pain - how it can develop and resolve; and
• To actively participate in their rehabilitation and healing.

Benefits of Groups
Whilst many people have reservations about joining groups, these reservations usually disappear early in the course. The atmosphere is friendly and supportive and there is no pressure to contribute to discussions: many people learn a lot from simply listening. The group provides inspiration, encouragement and a sense of “not being alone”. This can result in a rapid shift in mood and outlook. The emphasis is on ways to recover, not on complaints and grievances. Although grievances may need to be aired from time to time, they are not the main focus of the group. It is principally about education in self-management of pain.

Individual Sessions
Some people work better on a one to one basis and it may be preferable to do some, or all, of the work this way. A few individual sessions may help some people overcome an obstacle to developing their self-management program or returning to work. Others need to do longer term therapy, addressing deeply seated patterns of behaviour and beliefs, which are holding them back.

How You Can Support the Program ?

1. Familiarizing yourself with the course and its objectives will enable you to encourage and support your patient/client during, and after, the course. It could be helpful to listen to the tapes, read other articles on this site, look through the section on the posters, and browse the course manual.
   
   
2. Participants will be encouraged to complete a recording sheet for their program. This assists with lifestyle change and developing new routines. Your interest in, and support of this recording, would be appreciated.
   
   
3. When the pain increases many people panic and forget their pain management skills. A reminder about their self-management skills can help them through a setback/flare-up and help dissolve the panic.

Obstacles to Self-Management and Recovery
Obstacles to self-management and recovery can be related to difficulties the person has with the program but also include medico-legal issues and "doctor shopping". You can read about obstacles to developing self-management skills in the article about that. With “doctor shopping” there is a never ending series of visits to doctors in a search for a definitive diagnosis and a cure. It is extremely rare for people with chronic pain to get such answers, and part of the self-management approach, is learning to accept this fact. Once the chronic pain cycle is established, there is no single cause and consequently no single cure. If the team of treating practitioners all support this approach, it can be a great deal easier to make progress. Whilst some tests are necessary to rule out conditions requiring more invasive treatment, prolonged testing and opinion seeking can be harmful. Similarly, trying new methods of treatment and ceasing them after a few sessions when they don't work, can also create a sense of failure and a loss of hope and faith. When the person in pain is involved in litigation, it can be difficult for them to focus on self-management and recovery. Sometimes it is better to wait until litigation is completed. Finally, one of the greatest obstacles, is a failure to accept the mind-body or wholistic approach to management. Some people feel their condition is only valid if it is entirely physical. Within the compensation system, this can be an important issue and acceptance of the modulating effect of psychological factors appears to invalidate the claim and condition. If we help to educate our patients/clients and others to adopt a broader perspective, it may be possible to reduce the pressure on people in pain to prove that it is a physical problem.