What is the best way to manage chronic pain?

There are many ways to manage pain, and people usually have to find the ways that suit them. Overall, being aware of a healthy lifestyle including diet and exercise and allowing yourself to pace up to levels rather than having high expectations of yourself is a good idea. Medicines can help, used as prescribed, but if you are not getting any benefit from medicines then it’s advisable to talk to a clinician who is trained in chronic pain about alternatives. Go to www.chronicpainaustralia.org.au and view “Understanding pain in 5 minutes” as a good starting point, then read the fact sheets http://www.chronicpainaustralia.org.au/index.php?option=com_content&view=article&id=33&Itemid=109.. Staying connected with people including friends family and healthcare professionals that understand pain and how it works is helpful too.

A significant treatment method for chronic pain in addition to medication is exercise. Exercise helps to increase our pain threshold. It distracts us from the discomfort we experience throughout the day and provides us with a new element of life to focus on. Hydrotherapy is a great way to keep your body moving without feeling the harsh effects of chronic pain. This is because there is no gravity  in water. 

Hi Gaby,
I have just registered and I don't know how long ago you asked your question. This is a huge question. Managing persistent pain requires a biopsychosocial approach using multidisciplinary teams or many practitioners. Each case is individual and multi faceted depending on the type of injury and pain and the multiple contributing factors; biological, psychological and social.

Exercise does play a crucial role and it is very important to identify a baseline of activity that suits each individual; what level of activity can a person perform without firing up their pain? This baseline being established another crucial step is to implement correct pacing to try to prevent flare-ups of pain. This is only the active component; it is imperative that education on what pain is and psychological support be provided also.

Adding to the previous responses, current understanding about effective pain management of patients using the biopsychosocial approach involves:

• Educating them in non-jargon language about their pain experience, along with the difference between acute and chronic pain.
  
• Education about any physical cause/s of their pain and consequences of their disorder in factual, non-emotive, empowering language.
  
• Having treatment options explained relating to a physical cause and/or their pain.
  
• Being taught effective, customised self-management strategies where outcome and timeframe goals are realistic.  This commonly includes posture and movement modifications to help spare particular body structures from being chronically irritated, along with fitness exercises.  A gradual, rather than quick, increase in activity levels is usually necessary – pacing.  It is often helpful to commence with water-based exercises before progressing to increasingly challenging land-based exercises.
  
• Identifying, as early as possible, any unhelpful thoughts and behaviours about their physical problem and/or chronic pain experience.  Referral to a psychologist skilled in cognitive behavioural therapy (CBT) may be beneficial.
  
• Stopping any unhelpful treatments – particularly those in which a patient’s role is only passive and their self-management is limited.
  
• Educating them to expect and how to deal with progress setbacks and obstacles.
  
• Ensuring a supportive environment among those involved in the patient’s clinical care and life.  The aim is to help minimise intentional or inadvertent progress ‘sabotage’ and maximise lasting benefits.
  

 
Patients with simpler pain problems would likely achieve good results when managed by one skilled health care practitioner.  Multidisciplinary care – combined clinical assistance by practitioners with different skills – will be needed with increasing complexity of patient cases.  Where progress is still not satisfactory and for intractable pain, a more comprehensive multidisciplinary approach – such as with a dedicated pain management centre – has the greatest likelihood of success.
 
Whichever setting where clinical care and advice is provided, the overall goal of pain management is to improve a patient’s knowledge of their condition and optimise their physical function in spite of continuing pain.  As physical and psychological fitness improve as part of leading an active life, the impact of any ongoing pain is likely to gradually lessen.  In some cases, the chronic pain may eventually cease, while in others, unfortunately it will persist.
 
Lastly, many cases of chronic pain develop following episodes of acute pain.  Research studies have shown that if acute pain episodes are well managed by health care practitioners and patients, a good number of chronic pain cases can be prevented.

Hi Peter,
Everything you have described I totally agree with. An interesting point is that patients seem to thrive on understanding the complexity of pain; this is as you said decsribed in language that is appropriate for each individual patient. One of the most powerful statements is that pain is normal. Peripheral and central sensitisation are normal phenomena also and an understanding of these processes and how they occur can assist with persitent pain management. Once a patient understands why their nervous system is hypersensitive they will begin to understand why pacing is primary in their management.

Passive treatments have  a role depending on sensitivity in the nervous system; passive treatment may be seen as a thraet to sensitive tissue by the brain if it is already alert and focussing on pain from a specific region of the body. This is where passive treatments can fail and provide the patient with another failure that can heighten negative psycohoscial influences. Patients need to have positives in their management.  As therapists we need to identify when we should not treat and refer for pain amnagement at an appropriate facility.

Cheers Terry.

Hi Peter,
Pain is purely a sensory experience that is created in the brain not in the tissues of the body. In nearly all chronic pain states tissue injury is not the underlying problem, the time frame since injury is suggestive that tissues should be healed, central sensitiastion and plasticity are maintaining ongoing pain states. In these cases are passsive treatments any use in patient treatment and managment?

Cheers Terry.

G’Day Terry,
 
Good question.  My approach is to seek to understand the particular factors related to each patient’s chronic pain state and try to address these if possible.  If a particular passive treatment seems likely to help achieve the overall goal of gradually changing the incorrect conscious and unconscious perceptions of a patient’s brain about what stimuli are harmful, I’ll include it in the customised management plan.  As you’d know, with these types of health problems it can be a bit tricky at times to work out the ideal dose and intensity of manual procedures – massage therapy, mobilisation, adjustment/manipulation, etc.. 
 
Also, an important requirement in the management of chronic pain states, such as central sensitisation, is to help patients understand that:
a)     pain is a normal sensation, as you mentioned, and
b)    the brain creates a pain experience in an effort to protect the body from any perceived threat to it.  (The fight-or-flight feeling is also a normal response by the body to perceived threat.) 
The goal is to then use activity pacing and desensitisation techniques to help their brain to learn not to wrongly perceive certain stimuli as threats.
 
Regards, Peter

Hi Peter,
I agree with you wholeheartedly. It is obvious that you have a very good understanding of persistent pain; I hope that doesn't sound patronising. The words experience and perceived are strongly lnked to persistent pain. I use passive techniques where indicated as you have suggested but, as you wrote it is very important to keep in mind the sensitivity of the patient and what is the brain perceiving about the treatment; is it seen as a threat?

I don't know where you are Peter but this week I am attending a seminar at Royal North Shore Hospital on Pain in the Elderly. I know its not much notice but there are some very eminent presenters. Just thought I would let you know.
Cheers Terry.

Hi Peter, Terry, Gaby and all other healthsharers,

Just thought I would add a little to the discussion. I attended a neurodynamics conference run by the noi group (David Butler, Lorimer Moseley and co.) in Adelaide last month. This was overall a very informative conference.

I agree with what someone mentioned earlier in this blog - educating patients about the neuroscience behind pain appears to be quite a useful tool!

What do you think about this - An alternative to the word/ phrase perception with respect to persistent pain, is a mismatch between (sensory) expectation and reality. Conceptually this may be of value?

I appreciate your thoughts.

Regards, Neil

Hi Neil,
I think a distinction could be made here between perception of the individual persons beliefs and what the brain thinks is happening. Incoming barrages of peripheral info will sensitise the dorsal horn neurons (wind-up) and then if the stimulus continues central sensitivity will occur. Central thrsholds are lowered and central neurons will now respond much easier; central sensitisation. The brain is now responding to inceased info from the periphery and CNS particularly if the person continues to provoke nociception by activity.The brain will act by increasing pain to decrease a perceived threat. Pain can occur with minor movements even if there is no tissue injury.

This is where perception may be linked to psychosocial factors; what does the patient believe is happening?A lot of patients with persistent pain think pain equals injury when in most cases it doesn't. If healing has occurred and the activity should not normally cause a threat it will be likely central processes are involved as mentioned above. As Peter described in detail previously what is the threat? When pain occurs there is not just nociception involved. There are many areas of the brain involved also; the limbic system, the cortex, thalamus, hypothalamus etc. This is called a neuromatrix for pain and all of these factors thoughts, beliefs, emotions, stress can all cause pain as pain can cause all of the psychosocil influences.

Cheers Terry.

Hello,

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