Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Introduction

Pain is something that almost everyone experiences, but what may be surprising to learn is that around 20 per cent of the population have what is called chronic or persisting pain at any one time. Chronic pain is usually described as having pain on most days for at least three months. The causes of chronic pain are many, from nonspecific back complaints to arthritis to injuries to cancer. At present, most of these conditions do not have effective or lasting cures.

Some people are affected by chronic pain more than others, but it is estimated that about 10 per cent of the population of countries such as the UK, Australia, the United States, Canada, and those of northern Europe, report that persisting pain is interfering in their daily life. In some cases the pain can be quite severe and debilitating, where people may spend most days (and nights) lying down or are very restricted in their activities. In the other 10 per cent of the population, people with persisting pain report that while they don’t like being in pain, they have found ways to get around it and to get on with their lives to a reasonable extent.

This book is intended primarily for all those with chronic or persisting pain who would like to manage better than they are at present. Those who feel they are managing quite well already, may also benefit from some ‘finetuning’ or perhaps support for what they are already doing.

To give you an idea of whether this book could help you, try answering the questions in the checklist on page 2. On items 1 and 2, if you score 2 or less you should have something to gain from this book. On any of the items 3 to 18, if you score 2, 3 or 4, you should also have something to gain from reading and learning from this book. If you don’t score any 2s, 3s or 4s you probably don’t need to read this book, but you might find it interesting to compare your own methods with the ones described in these pages. 

Pain Self-management Checklist

M.K. Nicholas; University of Sydney Pain Management & Research Centre Royal North Shore Hospital, 1999 ©

How often have you used these pain self-management strategies (over the last month). Indicate your answer by circling one of the numbers (0–4) beside each item.

Thinking back over the last month, how often have you done these?

   

Never 

 Sometimes   

Very often

1.

If pain stops you doing something, do you ever work out other ways to do it. (Like, if you normally sit to do a task, but find sitting is difficult due to pain, have you worked out other ways to do it? Think of an example.)

0

1

2

3

4

2.

Taking regular short breaks when engaging in activities, including sitting or standing, which stir-up your pain (such as, stand up for 5 minutes every 20 minutes).

0

1

2

3

4

3.

Thinking that your doctors will find a cure for your pain?

0

1

2

3

4

4.

Using pain killers to allow you to do something you know will stir up your pain (like driving or standing too long, or carrying too much).

0

1

2

3

4

5.

Taking more than the recommended dose of any drug related to your pain; or using alcohol for pain relief.

0

1

2

3

4

6.

Taking a drug which only ‘takes the edge off’ your pain.

0

1

2

3

4

7.

Having one or more long rest periods (more than 45 minutes) (lying or sitting) through the day (8.00 am to 8.00 pm).

0

1

2

3

4

8.

Lying in bed at night worrying or getting stressed.

0

1

2

3

4

9.

Due to pain, having others perform your normal household duties (like washing-up, cooking, vacuuming).

         

10.

Doing an activity or task until it is completed regardless of pain and then resting.

0

1

2

3

4

11.

Due to pain, using aids (like sticks, braces, or collars).

0

1

2

3

12.

Seeing a physiotherapist or doctor or chiropractor or other health care provider about your pain (in the last month).

         

13.

Thinking that increased pain means you might have injured yourself (or made your injury worse).

0

1

2

3

4

14.

Thinking that doctors have missed something, or that you need more investigations to explain your pain.

0

1

2

3

4

15.

Thinking that pain relief is necessary before you can become more active generally.

0

1

2

3

4

16.

When your pain gets worse, do you ever have upsetting thoughts (eg, ‘I can’t go on; not again; why me?’)

0

1

2

3

4

17.

When your pain gets worse, do you ever take a tablet or have an injection?

0

1

2

3

4

18.

Do you ever make comparisons between what you are like now and how you were before the onset of your pain?

0

1

2

3

4

If you score 3 or 4 on several of these items you should read this book closely and discuss it with your doctor. It might also help if you discussed it with a physiotherapist and a clinical psychologist with experience and training in cognitive-behavioural treatments.

If you have had this pain for more than six months to a year and no treatment seems to be helping, you should speak to your doctor about being referred to a multidisciplinary pain clinic for specialist assessment and help. Most large hospitals have a multidisciplinary pain clinic and many of these will have people who use the types of methods described in this book.

This book is based on the authors’ clinical experiences in hospitals in Australia and England over the past 30 years of treating people with chronic pain. It is also based on the work and studies of clinicians and researchers from different disciplines in many countries, starting with Professor Wilbert Fordyce and colleagues from Seattle in the US in the early 1970’s.

More specifically, the program described in this book has been developed by the authors at the University of Sydney Pain Management and Research Centre at the Royal North Shore Hospital in Sydney since 1994. We call our program ADAPT, as that really sums up what it’s about. The ADAPT program that we run at the hospital is very intensive. Patients attend all day, Monday to Friday, for three weeks. This book is the basic manual we use. It has been revised so it can be used as a self-help book, but we recommend that it be used in conjunction with your doctor, or other health provider.

ADAPT was itself based on work done by Dr Nicholas and colleagues at St Thomas’s Hospital in London, beginning in 1988. The program at St Thomas’s, which we called INPUT, started out as a research project to evaluate the effectiveness of the treatment over a one-year period. Two versions of the program were compared with standard medical management of mainly just medication. The results showed that patients doing the two programs improved more than those receiving standard medical management only. Of the two versions of the program, those who attended the more intensive approach did better and this effect was still evident one year later. The more intensive version involved staying in hostel accommodation at the hospital and attending the program all day, Monday to Friday, for four weeks. The less intensive version involved patients staying at home and coming to the hospital one afternoon a week for eight weeks. Patients who attended the programs did better in terms of reduced use of medication, improved mood, improved confidence and improved activity levels. They became a lot happier and could do a lot more of their normal daily activities. They still had their pain, but it was no worse and it didn’t trouble them as much as it had before. 

If you are interested, an account of this study was published in the journal Pain in 1996 (Volume 66, pages 13–22). This journal is published by the International Association for the Study of Pain (IASP) and it is the leading international scientific journal in the field of pain.

The two main lessons we took from this study were first, the methods taught in the program are more effective than just taking medication alone, and second, the methods taught in the program are more effective if the person doing it works on them as intensively as possible.

In other words, simply doing the program in a half-hearted way is not likely to be as effective as really putting some concentrated effort into it. So, if you don’t feel confident about doing this program on your own, you should ask your doctor if he or she can suggest a local clinical psychologist and physiotherapist who might be able to help. Alternatively, your closest pain management clinic might have a similar program on offer.

Although claims have been made for many different treatments for chronic pain, especially back pain, the reality is that there is no magic bullet or simple solution for chronic pain and the many problems it causes. As attractive as a quick fix would be, it is essential that all consumers of health care services remain critical of reports of breakthroughs and cures in this complex and difficult area. Almost without exception, reports in the popular media about breakthroughs in treating chronic pain have proved false. Even treatments with seemingly good scientific support do not help everyone. Equally, some people seem to benefit from almost any treatment that is devised, but that doesn’t mean the treatment works for most people with the problem. Some treatments are even harmful.

This book does not claim to have all the answers, but the methods and strategies described have been supported by research in a number of countries and a list of many of these studies is provided in Appendix 1 on page 267.

Unlike a new drug or device that might be expected to ‘fix’ your pain for you, this book offers no instant relief. Nor does it promise total relief at some time in the future. Instead, it describes an approach to managing pain in which you, the person in pain, are expected to play an active and ongoing role. Whether it helps you achieve your goals will depend on many things. These include: 

Overview Of ADAPT Program

The main stages of the program are outlined here.

See the individual chapters for further information on each topic.

·        how realistic your goals are (going parachuting may be too much to expect)

·        how well you put the methods into practice (just as if you clean your teeth only once a week you wouldn’t expect to have good teeth)

·        how much you actually want to achieve your goals (if it would only be ‘nice’ but not really important, you probably won’t try)

·        how much support you have in your environment, at home and at work.

At different points in the book you will be asked to think about each of these issues, along with many others. The essential point is that the book is a manual. The information in the book will not change your life by itself. Only you can do that. To some extent, you have to become your own doctor/physiotherapist/psychologist. But don’t despair, the book will provide guidance on all these matters.

It is our intention that the book should provide a person experiencing persisting pain with a useful guide to managing their pain themselves. We would recommend that those intending to use the book should first discuss it with their doctor, physiotherapist, chiropractor or other health care providers. If possible, it would be useful to work through the book with a health care provider acting as a sounding board. We do not want to suggest that the methods described in the book are always easy to apply, especially if you are feeling overwhelmed by your pain. If you or your doctor feel that you might need more help then it may be appropriate for you to attend a local pain management clinic where specialists in pain medicine could assess you and provide expert help.

We would also strongly recommend that you see a qualified medical practitioner to assess your pain before you try to use the book. Your doctor may not be able to offer you any curative treatment, but he or she can certainly make sure there is nothing seriously wrong with you.

If necessary, your doctor may need to refer you to a specialist. At least you should be able to get a reasonable idea of why you have persisting pain in the first place. Clearly, if the cause is treatable, it should be treated. If there is no cure available, you will need to come to terms with having persisting pain for the forseeable future. Fruitlessly searching for a non–existent cure can end in frustration, helplessness and even despair. Not to mention the costs, to you and your family. Hopefully, you will find that this book can help you to avoid the pitfalls we all face when pain persists.

If your doctor or other health care provider disagrees with some or all of the approaches used in this book, we suggest that you discuss it with him or her. It may also be helpful to get another opinion. You could also ask your doctor if they have any better solutions and what evidence there is to support them. We strongly advise against simply accepting advice from any health care provider based only on their opinion or experience with another patient. Such opinions do not amount to good evidence in medicine these days. All health care providers have a responsibility to give you evidence to support their opinions, and that evidence should stand up to scrutiny by their peers.

The book is divided into topics. We advise you to move back and forth through different chapters as recommended in the text. Thoughtful reading and discussion, especially with other family members or good friends, can help someone suffering from persisting pain to gain new perspectives on their pain. Practising the methods outlined in this book will help you to improve your pain management skills. In turn, these improvements can result in less suffering and restoration of a more normal lifestyle despite persisting pain.