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Last month I tried to explain the complex nature of pain, in particular persistent pain, and the influence of various factors well beyond the initial tissue damage itself.  Pain management too needs to be multidimensional, and individualised to a particular person's circumstances.

Pain Management
The term itself implies that the goal is not necessarily to "cure" the pain.  This itself can be a challenging proposition to accept, but for many people this is the reality.  The aim of pain management is therefore just that, to assist you to best deal with the physical and emotional consequences of chronic pain, and give you the tools to live a fulfilling life, albeit with limitations.  Persistent pain can be tackled from many angles.

Education
A vital first step is to have your pain explained to you, and evidence confirms that this alone can have a major effect on your ability to cope.  It is important for people to understand what may be causing their pain, and why it has not gone away.  An explanation along the lines detailed in the previous article (Part 1, April Newsletter) can help rationalise what one may be feeling, help them to understand why the pain may fluctuate irrespective of their physical activities, and often ease anxiety about their pain.  Simply being told that your condition is not life-threatening, it is not cancer, or that you will not end up in a wheelchair due to your sore back for example, can ease a tremendous amount of stress for some people.  Two examples of good quality, free online pain education videos are available via www.youtube.com/watch?v=4b8oB757DKc, and www.youtube.com/watch?v=L4oy2LnoDZA.  

For a more comprehensive education and self-help guide, you can not go past the excellent book "Explain Pain" by David Butler and Lorimer Moseley.

Medication
At the centre of the management model for persistent pain is a good GP who can optimise your regime of medications, be they analgesic or anti-inflammatory drugs, anti-depressants, muscle relaxants or specific ones for nerve pain.  They can help to minimise side effects and interactions, and they act as a hub for referral to other health providers.  Sometimes we think we're doing the right thing by toughing it out until the pain is unbearable, when instead our average pain may be less, with less fluctuation, and we are able to do more by taking regular tablets.  Be guided by your GP.

Change your thinking
Talk yourself better - sounds strange, but changing the way we think and feel about our pain has been shown to be highly effective for easing pain, improving control over our pain, and minimising the harmful effect of pain on our lifestyle, work, relationships, etc.  Psychologists and physiotherapists experienced in pain management can assist with this Cognitive Behavioural Therapy, designed to empower you, to get you in the driver's seat rather than become a victim of the pain, and to make positive choices, using helpful thinking.  For example, instead of "I can't cope with the pain", try "I find it difficult to deal with the pain".  And rather than "I have to do these exercises", or "I have to take these tablets", think "I choose to do this to control my pain so that I can . . ."   

It helps to focus on what you can still do and not what you can no longer do, and to challenge beliefs that more pain equates to more harm or tissue damage, when this is most often not often the case.  A psychologist can further help you to work through emotional trauma, anxieties and fear, depression, anger, disrupted sleep patterns, motivation issues, and work conflict.  Speaking with a medical professional about how you are feeling can be especially helpful if you feel that those around you do not understand what you are going through. 

Improving sleep
Contrary to many peoples' beliefs, scientific studies have concluded that poor sleep results in more pain, rather than vice versa.  If we are able to improve the amount and quality of our sleep then our pain levels correspondingly can improve.  Some simple strategies include turning the bedside clock away, sticking to a bedtime routine, avoiding exercise or stimulating activity immediately before bed, avoiding caffeinated drinks after about 3pm, and keeping the bed solely for sleep and sex.  If you need to get up overnight, avoid bright lights or stimulating activities such as the TV - just do a boring activity in low light until the next "wave" of sleep comes.  Try having a pencil and paper by the bed and jot down your worries or the things you need to attend to the next day.  Or consider a relaxation CD, such as those by psychologist Sarah Edelman.  And finally, DON'T WORRY about sleep, no-one ever died from not sleeping!  

Set Goals & Return To Life
Think what you would do if your pain was better, and try to focus on slowly improving your function.   Pace yourself, find the right balance between activity and rest, so that you can achieve progressively more over time.  Maintain social contact with family and friends and work colleagues, and remain at work where possible.  This is excellent for self esteem, and even if your work is not particularly physical, the evidence is strong that the longer you have been off work, the more difficult it is to return.  It is important to continue activities that don't aggravate the pain too much, and ones that you enjoy or which give you satisfaction.   And aim to reduce reliance on others to "fix" your pain, and minimise passive inputs - ask yourself  "How is this intervention helping me to work towards my goals?".  A physiotherapist can work with you to formulate a program of appropriate and safe exercises to keep you active, and allow you to make small, slow, sustainable functional gains.  This in turn can often "iron out" the pain fluctuations (see chart).

It is OK to set unrealistic goals - you will either have to learn to accept that you cannot achieve something, or you will work together with your treaters to find a way to work towards it.  Either way it is a journey and a useful exercise.  Good luck!

Peter Biskup  
B.Physio(Hons), M.Physio(Musc)
APA Titled Musculoskeletal Physiotherapist

Email feedback or suggestions for future articles to bannockburn@coriobayhealth.com.au