When your pain management skills seem to have stopped working

Hard times or a change in routine can have a big effect on how you manage your pain. But you can get on course again, says Dr Deborah Tinson.

A number of patients contact us to say that they are feeling quite stuck in their attempts to manage their pain. They have been following pain management principles for some time but a new problem has occurred and they can no longer find their way forward. I have invented “Bill” as an example of the way in which this can happen. Below is some of the advice we would give him.

Bill

Bill’s problems began in the 1970s. He had pain and stiffness across his lower back and a numbness and tingling in his arms and hands. The doctors told him that he had degenerative changes in his spine and that an operation would not help.

In general he felt that he coped well. His work as a salesman involved long periods in the car but he got up early to stretch and loosen up and took frequent stops on the road. He exercised and walked the dog daily and felt reasonably fit. He had not been off work with pain for some years.

In 1996 he and his wife decided to move house. Selling was stressful and the move involved lifting, which aggravated his back. However, he understood the reason for the flare up. Afterwards he put his usual strategies into place for two weeks with his wife’s support, cutting back on activity baselines and making more time for relaxation. The problem began to settle.

Then, out of the blue, his wife had a car accident. In addition to worrying about her and hospital visiting he had to look after the house and her elderly mother. In order to do this he pushed through the pain telling himself he would be able to cut back once his wife was well again. He often took extra tablets and learned to ignore the pain and push on for as long as possible.

After a few months his wife was back at home and doing light housework but she needed his emotional support. He still had to look after her mother. He cut back on walking and exercise levels but felt no change in pain. He felt tired all the time. He could no longer see which activities were causing increases in his pain. He couldn’t concentrate on his relaxation. Nothing made a difference. He began to wonder if the fact that the strategies had helped before was just a fluke. Maybe he had done some damage during the house move and not realized it. He gave up his exercise programme. He went to see his doctor who said that there were no physical changes. He could not reduce his medication. He felt helpless and could see no end to the problem.

Comment

Bill was discouraged when this flare up did not settle as before. However, he has forgotten that this time the cause of the flare up IS different. He has had months of putting other people’s needs before his own and overriding his pain in a “mind over body” approach. He is still doing more than he used to. Importantly, this time his mood is lower and his wife has been unable to help him.

As the links between his activity and pain are now less clear, Bill feels out of control and hopeless. Psychologists call this “learned helplessness”. It is the belief that nothing we can do will make any difference to the negative things happening to us. It may lead us to stop trying to solve a problem and it may be an important cause of depression.

Advice

One option Bill has is to put a management plan into place again. This may take longer than he is used to, so he must watch for negative thoughts and keep an open mind on how long this will take and the eventual outcome.

In order to relearn about his body, Bill could start by keeping a daily diary of pain, activity, mood and pills. The pattern of pain may have changed but a new pattern may become clear. One person found that his pain was no longer linked to any particular activity but built up over weeks and then went down. He realized that when his pain was lower he did not overdo any one activity but would just very slightly increase all activity baselines until the pain increased and he rested. Another realized that the pain had a closer link to fatigue than before.

To overcome learned helplessness it is important to take part in enjoyable and
challenging activities. Bill might set aside a little time for a hobby or activity which helps him to switch off from his worries (craft, phoning friends, cooking). He needs to focus his thoughts onto those aspects of his life that he can control rather than on the things, which are out of his control.

Relaxation time is always an important part of listening to our body and altering body tension will give us a sense of control. Poor concentration and increased pain make this difficult for Bill. Shorter spells of time focusing his attention onto breathing exercises or music or helping muscle relaxation with the heat of a bath or Jacuzzi may be things he is most likely to succeed with at the moment.

Bill will of course want to review his baselines. Getting back to his exercise at an achievable level may help him with fitness, tension and fatigue. He will notice that one extra activity he still has is looking after his mother-in-law. If Bill is still going to do this he may need to cut down on another activity, change his priorities, or get some help. He will need to be assertive in asking for help from family or professionals but if he does this, may feel good that he has looked after himself.

Stepping back from a problem and sticking to a plan is difficult when we feel low. Low mood is associated with low energy, poor concentration and negative thoughts which will all get in the way. Anxiety and tension may make us rush and fall back into old habits such as wanting quick results. Bill might seek the support of someone who will understand and help him review his plan. This might be a friend or relative or his GP may recommend that he see the practice nurse or community psychiatric nurse. Seeking support like that is a positive coping strategy. Other people can help us to see another angle on a problem, give new advice or help us to stick to a plan when we are finding it a struggle.

Message

A change in routine or event such as illness, a wedding or moving house can have a big effect on how you manage your pain. If the event is very stressful, or there are several events in a row, it can affect both your mood and your pain. This makes it difficult to get on course again. It becomes even more important to look for negative thinking patterns and to tackle these. You need to remind yourself that looking after yourself will help those you care about too.

So I thought I knew how to manage my pain …

Lynda Hepburn benefitted greatly from learning pain management skills, did well for some time but then hit a difficult period. She describes coping with a prolonged flare up that seemed to come from nowhere.

Deborah Tinson’s words could have been written especially for me. Attending the pain management programme had been a turning point in the long and tedious saga of my back pain: in short, I had learned how to manage it in order to feel in control, increase many activities and have less daily pain.

Future looked good

While finding all parts of the programme interesting, I had concentrated on the exercises and stretch programme and on pacing activities. In this way I had got back to swimming, increased the amounts I could lift and carry and generally become more fit and supple with increased stamina for most activities. Within two years I had succeeded in building up my business as an ecological consultant, managing to cope with both deskwork and being out in the field for whole days. The future looked financially fairly good and I felt confident that I could cope both as a single parent and as a breadwinner.

Then one day I sat on the floor leaning against the sofa for five minutes and the next day I put my wellies on standing up rather than sitting on the back bumper of my car. That seemed to be all. The flare up which resulted has now lasted thirteen months, during which time all that I had learned seemed to be useless in achieving any improvement. Work had to stop, all travelling impossible, only one chair tolerable, pain forced several sessions per day in bed, depression set in …

Reached a barrier

Deborah Tinson refers to learned helplessness - I know it well! I tried my exercises, but could never build up more than three or four repetitions before a mini flare up would land on top of the major one. I tried the stretches which had helped me so much before, but found that I could not even get into the starting position for some and as soon as I began the stretch it would aggravate the pain. I tried to pace up my walking but reached a barrier beyond which I couldn’t make any headway.

Discovering relaxation

After a few months of struggling like this, I finally turned to the parts of the programme which I hadn’t paid much attention to before. Top of this list was relaxation. As I had to lie in bed so much, I thought I might as well try to relax more while there. Of course there was little progress to begin with: relaxation doesn’t provide any quick fixes (especially as I had more or less ignored this technique up till then). Now, having practised two or three times daily for eight months, I’m noticing some changes. I can significantly relax certain muscles in a session of 15-30 minutes and the beneficial effects can last for up to a few hours. I have also discovered that places which I believed to be relaxed are anything but: muscle tensions can become so habitual that we think they are normal. I have a left shoulder which will now relax when I think about it, but is otherwise slightly clenched all the time, even when I am asleep.

Going by the clock

It is interesting to ask myself why I didn’t make use of relaxation techniques before this current flare up? The obvious answer is that the other parts of pain management were working well for me, so I didn’t need it. But the less obvious reason in my case is that relaxing felt like not doing whereas stretching and goal setting felt like doing to me. As I am a self-confessed doing person with an often unhelpful tendency to perfectionism, lying still was one of the hardest things to take on. Another aspect which only dawned on me recently, was that I tended to lie down once pain increased. Lying down was then associated with recovering enough to stand up again: relaxation became linked to ‘giving in’ - only to be done when pain necessitated! Now I have spotted this, I plan my relaxation sessions like any other activity i.e. by the clock. This way, going back to bed at 10.30 a.m. feels like a positive activity, not a failure.

Coping better

So I’m still in flare up but coping better, doing more and feeling in some control again. What I have realised this time is that my old routine of stretch, exercises and some pacing are not adequate to my current situation: relaxation needs to be added along with some changes in attitude about it. The pain management programme covered a multitude of topics and there are more techniques of which I haven’t as yet made full use. I need to reassess how I am using those techniques when pain management seems to have stopped working for me.

Dr Deborah Tinson is a Clinical Psycholist with Astley Ainslie Hospital Pain Management Programme.

British Pain Society, 3rd Floor, Churchill House, 35 Red Lion Square, London WC1R 4SG, http://www.britishpainsociety.org can give you or your doctor information about pain clinics and pain management programmes. http://www.britishpainsociety.org/patient_publications.htm - direct link to the most up to date publications from the British Pain Society
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