Treatment Plan: Do Nothing?

It’s cold and flu season again and we all do the best we can to stay well and avoid catching an all-too-contagious virus. We each have our own go-to plans of how to fight it: vitamin C, zinc or elderberry supplements, gargling with salt water, staying warm, rest and binge-watching Netflix shows. My grandmother swore by anise candy that she made from scratch, while my father prefers a hot toddy to remedy a cold. Washing hands is still the number one way to avoid illness — along with avoiding contact with your face, and keeping your immune system strong. Far too many of us have also taken antibiotics despite the fact that they do nothing for a virus and their overuse has now created resistant strains of bacteria for all humans (Ventola, 2015). You may be tempted to go to the doctor for antibiotics “just in case,” and then the antibiotics are falsely credited for your recovery since you always do eventually recover. Primary care physician and medical director at Chapa-De Indian Health, Dr. Mike Mulligan, says in reference to antibiotics, “If I do nothing I will be doing right by patients most of the time compared to if I prescribe something. If I prescribed antibiotics for everyone who wanted them, I would most often be doing wrong.”

Typically when we go to the doctor we expect someone to do something, yet overtreatment is far more common than under-treatment and the impact causes real harm. Dr. H. Gilbert Welch has investigated how and why this happens for many health problems including heart conditions, headaches, back pain, knee and hip joints, gastrointestinal disorders, and even cancer. In his book Less Medicine, More Health (2015), he examines how early detection hasn’t led to saved or improved lives, which defies logic at first glance. The over-prescription of medications alone is nothing short of epidemic, most glaringly seen with the overuse of opioid pain medications.

Chronic pain is that much more frustrating because of its long duration and frequently leaves people feeling Something More Should Be Done. It seems like Something Else Must Be Wrong if only the doctor could find it. Each specialty department shakes their heads and gives the “good news” of normal or inconclusive scans. Navigating health care systems is not easy to begin with chronic pain rehab programand there are still far too few comprehensive pain management programs that focus on functional rehabilitation. Once in a while the ragged pursuit of Something Else can lead to a more thorough workup or referral to a good treatment program. It depends where the Doing More is directed. Too often, the quest for the Something Else leads to tests and treatments that carry their own risks without relief; often frustrating and distracting to the patient and doctor, resulting in more pain, medical appointment exhaustion, and patients feeling demoralized and hopeless.

Chronic pain has few circumstances where invasive procedures are the best choice. Usually if surgery is warranted it becomes quite clear early on and a 2nd or 3rd opinion will render the same conclusion. The risk of more pain is high with surgery when done because “it might help,” even if the structure has been “fixed.” To a surgeon, fixed means correcting the abnormality. To you as a patient, fixed likely means less pain and improved function. The past 30 years has revealed that abnormal scans of the lumbar spine are common among pain-free individuals and normal scans are common among those who experience pain (Jensen, et al., 1994; Borenstein, et al, 2001). So if the abnormal is normal and abnormal findings do not predict pain, what do we do now?

Last week my daughter’s knee swelled up larger than a softball until she could no longer bend it. We had an x-ray and waited. And waited. The swollen mass grew bigger and her doctor reassured us that ice, elevation and anti-inflammatories were the best treatment. This was hard for me to believe and my mind raced: What caused it? There must be a reason! Why is it so large? Can’t we test the fluid? Can’t we do something to make it go away quickly? I felt like I was Doing Nothing and this felt terrible, but her doctor had ruled-out life and limb-threatening infection and it was the right call. Had I gone to the emergency room, the fluid may have been tapped, risking infection, leading to antibiotics, potential complications and unwanted effects, including more time in bed. An MRI may have revealed an abnormality that was unrelated, which could have led to Doing Too Much. My worst fears were not realized, but it was tempting to buy into the fear that Doing Nothing would lead to a bad result that could have been avoided if I had Done More. What felt like Doing Nothing really was doing something – something at home (elevation, ice, anti-inflammatories, and coping with fear and pain) and Nothing More at the hospital.

The Temptation

It is tempting to assume:
• If there is pain, something is wrong.
• If something is wrong, it can and should be found if we look hard enough.
• Once it is found, it can be fixed.
• If it is fixed, I will feel better.

These assumptions are myths that have been dispelled over time. Sometimes we hurt without any abnormal findings. Sometimes looking harder leads to more problems rather than fixes. Even if the source of pain is found, it may be best to avoid invasive treatments. And the fixing of found abnormalities helps — if you are a car (but even then be cautious of overtreatment!).

But isn’t the pursuit worth the risks? Welch’s data suggests not. One common example is a CT scan – the radiation may increase cancer risk and should be avoided whenever possible. But there also are lesser known risks he calls “incidentalomas” – those incidental findings that appear abnormal on a scan, but do not actually explain or contribute to the symptoms you are experiencing. These red herrings lead to many unnecessary procedures including what I call health-ectomies, or removal of healthy organs in the hopes that it will solve the problem. This is very common in abdominal pain, one of the leading causes of emergency room visits (CDC, 2011). In our highly medicalized society that relies on technology to save us, we can be misled to think that everything can and should be found on a scan or test. However, the search may only distract you from good self-care in the pursuit of an outside fix. Living in the information age leads us to think that more information is better, but more is not always better. “Better information is better,” Welch says (2015). We need useful information to move forward with clarity in medical decisions and health. “At least I would know” does not work if it distracts you from the truth. The truth may be that your disks are degenerating, but it is not typically the cause of your discomfort.

The Frustration

It’s frustrating to be told no, you don’t need that test, that the cause of your do nothingsuffering is unknown, or that there is no cure. “That’s all I can do,” are not words we like to hear. They rank up there with “Could it be depression?” Your doctor may or may not have explained to you why more tests are not recommended. Some people suspect it’s to save money, but most clinics have financial incentives to perform more tests, not fewer. You as the patient may feel more taken care of, more thoroughly examined, but it may not lead at all to better care. Sometimes it is best to Do Nothing, at least nothing at the doctor’s office.

The Fear of Missing Something

The Fear of Missing Something is real and powerful. Any doctor can tell you how terrible it feels when something has been missed. It haunts them for a lifetime. This is a fear of patient and doctor alike, although it is overtreatment that is the common daily occurrence. Most of us feel better Doing Something. Mistakes are made when we are guided by fear rather than facts. We depend on doctors to rule-out anything life-threatening. Afterwards, it can feel devastating when it’s suggested that you “learn to live with it.” But this is not because doctors don’t care enough to do more. Most health care providers really do care, and they care enough to do less. This is where their job ends and yours continues.

Chronic pain is often part of a feedback loop with the central nervous system that becomes sensitized even when the pain signal from body to brain carries no new or useful information about the condition of the body. Inflammation and degeneration are common pain-related issues best treated by lifestyle improvements. A spinal fusion may “fix” the current instability, but create more instability in surrounding areas. It may “fix” the problem, but also severely decrease range of motion. Medication almost always has unwanted effects. Injections have risk and the benefits must outweigh the risks for it to be a good choice for you. Physical therapy may hurt and you swore you would never go back, but finding a physical therapist who specializes in chronic pain is a key part of rehabilitation. Dr. Nobert Boos and colleagues (2000) found that the physical and psychological aspects of a person’s job predicted pain over a 5-year period better than MRI results. If the chronic stress of a tyrant boss or conflict-filled relationships are fueling inflammation in your body, you might consider treatment that targets these root causes of inflammation rather than pursuing a traditional medical fix targeting the wear and tear that’s found on MRI.

Often the body does best when it’s left to its own devices rather than modern medicine interfering at all. You may feel like More Should Be Done, but for chronic and stable conditions or the common cold and flu, wellness is best found at home, not at the doctor. Self-care is a full time job and the goal is to get so good at it, less effort is required over time.

References

Boos, N, Semmer, N, Elfering, A, et al. (2000). Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity. Spine, 25, 1484-1492.

Borenstein G., O’Mara, J. W., Boden S. D., Lauerman, W. C., Jacobson, A., Platenberg, C., Schellinger, D., & Wiesel S. W. (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. Journal of Bone & Joint Surgery, 83, 320-34.

Centers for Disease Control (CDC). (2011). http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf

Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. D., Malkasian, N., & Ross, J. S. (1994). MRI imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 369-373.

Schwartz, A. L., Landon, B. E., Elshaug, A. G., Chernew, M. E., & McWilliams, M. (2014). Measuring low-value care in Medicare. JAMA Internal Medicine, 174(7), 1067–1076.

Ventola, C. L. (2015). The antibiotic resistance crisis. Part 1: Causes and threats. Pharmacy and Therapeutics, 40(4), 277–283.

Welch, H. G. (2015). Less medicine more health. Boston, Massachusetts. Beacon Press.

Date of last modification: 12-22-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

Finding Hope in Acceptance

At first thought, it might seem crazy to accept that your pain is chronic. When I bring it up with patients, many of them tell me, not without some irritation in their voice, “I’ll never give up hope of finding someone who can fix me!” Indeed, it’s common to think that accepting the chronicity of your pain is the same thing as giving up hope that you’ll ever get better. So, why in the world would you ever want to accept that your pain is chronic?

Contrary to what you might think, accepting that your pain is chronic is the first step in actually getting better. It opens up a whole new way of getting better, a way that takes into account the realities of your pain condition. As such, it’s a new and more realistic way to have hope.

To understand the point more clearly, let’s briefly review two different models of healthcare – two different ways that we get better when having an illness or injury. These two models are what we might call the ‘acute medical model’ and the ‘rehabilitation model.’ The latter is sometimes called the ‘self-management model.’ (For a more thorough review of these models of healthcare, click on this post here.)

Acute Medical Model

The acute medical model of healthcare is what most of us think of when we go to see a healthcare provider. When sick or injured, we go to a provider who determines what’s wrong and provides a treatment that cures us. The healthcare provider is an expert who usually knows more about the condition and the treatments than we do. The treatments themselves are usually medications or procedures that act on us. We don’t typically get better by doing things ourselves. Rather, it’s the treatments that get us better and we rely on healthcare providers to provide us with those treatments. Lastly, getting better in the acute medical model is usually thought of as getting cured. We return to our usual state of health — how we were before we became ill or injured.

Hope of getting better within the acute medical model lies in finding the right healthcare provider who knows what’s wrong and knows how to cure you. In this model, hope lies external to you. You find it in the expertise and treatments of a healthcare provider.

Now there’s nothing wrong with the acute medical model. It’s all well and good when we have a condition for which there actually is a cure. Indeed, it’s likely the best thing to do. But, what do you do when you have a condition for which there is no cure?

Rehabilitation Model

The answer to the question, of course, isn’t to give up hope and do nothing. There’s actually a different way of getting better. It’s the rehabilitation model of care. It requires, however, redefining how to get better and even redefining what it means to get better.

In the rehabilitation model of care, the emphasis is on what you, the patient, do to get better — not on what the healthcare provider does to get you better. Specifically, the focus is on the patient acquiring the abilities to make healthy changes, which, when done over time, have a positive impact on the chronic health condition that you have. These changes fall into two categories: a) changes in health behaviors, or what’s often referred to as lifestyle change, and b) changes in coping, or what’s often referred to as stress management. The goal of learning and engaging in these health behaviors over time is two-fold: you reduce the symptoms of the condition and you reduce the impact that the chronic health condition has on you. In other words, you get so good at self-managing the condition that it no longer is as problematic as it once was. As a consequence, you can move on with the rest of your life, engaging in the meaningful activities of life – such as work, family activities, social and recreational activities.

Notice that the rehabilitation model doesn’t promise a cure. The reason is that the conditions for which the rehabilitation model is best suited are those conditions that are chronic. They have no cure. Nonetheless, the patient does get better in very real and meaningful ways.

Notice too that hope gets redefined. It allows for having hope even when there is no cure. Finding a cure is not the only way to get better. Therefore there’s still hope. It’s just a different way to have hope, a hope that realistically takes into account the chronic nature of the condition you have, but nonetheless points to how to how you still can get better.

The conditions for which the rehabilitation model is best suited are chronic conditions, where there is no cure, such as chronic pain syndromes, diabetes, heart disease, and spinal cord injuries, among others.

Finding Hope in Acceptance

Acceptance that your pain is chronic is the first step in pursuing the rehabilitation model of care. Rehabilitation is hard work. It also takes time. You don’t do it if you think that a cure is just around the corner. Once you recognize, though, that your chronic pain really is chronic, it becomes your life-saver – or life-retriever. You start to get your life back. You learn how to self-manage your pain and you practice it to the point that you move on with the rest of your life. Your life doesn’t have to be about chronic pain.

Patients can keep their life on hold when they insist on finding hope only in a cure. They seek out appointment after appointment, attempting to find the right specialist who will know what to do to make their pain go away. Oftentimes, they seek out surgeries or interventional procedures that seem as if they might be a cure, but aren’t. Each time they seek out a new specialist, there is hope. Each time, though, it gets dashed because there really is no cure for chronic pain. Chronic pain really is chronic.

The point, here, is not a criticism of such patients. What we are describing makes sense if you think of healthcare as only the acute medical model. If we think of healthcare providers as specialists who fix us when sick or injured, it makes all the sense in the world to look for the right one who can do the job – even if you have to try one after another. It’s a hard lesson to learn when realizing that it’s only sometimes that healthcare providers act like a mechanic. A lot of the time, we have no fixes. So, again, I’m not judging when I describe patients who fail to accept that their pain is chronic.  We can all understand how it happens. They are trying to find hope in a cure.

What if, though, at the end of the day, the hope is really a false hope? It can become a vicious cycle that leads to depression and oftentimes more pain. Hope is found with each new procedure, but each procedure fails to cure the pain and so hope is dashed. If hope is defined by finding a cure, and if there really is no cure, then you are left helpless – and hopeless.

Maybe it’s best to find a new way to have hope.

You find it by accepting that chronic pain really is chronic. You accept that you are not going to get better by finding a cure. Rather, you accept that you are going to get better by learning to self-manage it. You learn how to make healthy changes in your life that, when done over time, reduce your symptoms and reduce the impact that chronic pain has on your life. You get so good at managing chronic pain that it is no longer the preoccupying problem that it once was. Your life consists of the stuff of life and chronic pain comes along for the ride, but remains in the side car.

It’s okay if you don’t know how to do it yet. Most patients have to learn how to do it. Oftentimes, I remind patients that you’re not born with the knowledge of how to self-manage pain successfully. People have to learn it. And it’s okay if you don’t know how and have to learn it.

What matters, though, is that you learn how. It’s possible to learn how to self-manage pain and do it successfully. People learn how to do it everyday in chronic pain rehabilitation programs. And you can too.

You just have to first accept that your chronic pain is really chronic.

(For more information, please see: “What is chronic pain?” or “Why the healthcare system refuses to accept the chronicity of chronic pain.”)

 

Author: Murray J. McAllister, PsyD

Date of last modification: 8-26-2013

Coping with Pain: How People Who Cope Really Well Do It

If you wanted to learn how to knit well, you might take a class at your community craft store. You might also get a how-to book out of the library or watch a few YouTube videos. But as you did all these things, you would also pay attention to those who already knit well and watch how they do it. You would then try to do what they do. The same thing would be true if you wanted to learn how to play a musical instrument well or play a sport well or fish well. Say, for example, you wanted to learn how to become a better guitar player. You would probably take lessons from a teacher. You might read how-to books and watch videos on the internet. But you would also listen to how really good guitar players play. And you would try to play like them.

Why shouldn’t the same thing be true with coping with pain?

If you wanted to learn to cope with pain better than you do at present, then you likely would do a few different things. You might find teachers to teach you how (usually, when it comes to chronic pain, such teachers are called chronic pain rehabilitation providers and are found in chronic pain rehabilitation programs). You might read about how to do it (such as in blogs and self-help books). You might also watch videos on the internet (such as this one here).

Also, though, you might try to learn from those who cope with chronic pain really well. Just like learning any other skill, it is helpful to learn from those who do it well. You learn what they do and then try to do it yourself. Of course, like any skill, it takes practice and sometimes it takes a lot of practice.

Looking at coping from this perspective takes the mystery out of it. Coping with pain involves skills like any other skills. In this way, it is just like knitting, playing tennis, fishing, or playing the guitar. These activities are all a set of skills and similarly coping with pain is a set of skills. Like any other set of skills, the more you learn about how to cope and the more you practice, the better you get at it.

Skills, like coping with pain, might be thought of as occurring along a spectrum in which there is no endpoint. There is no point at which you are as good as you possibly ever will get. No matter how good you are at a particular skill, you can always get better with learning and practice. Whether you are a novice tennis player, a pretty good tennis player, or a professional, you can still get better at playing tennis. You can always hone your skills and get better with practice. The same is true with playing a musical instrument. Whether a beginner or a virtuoso, the musician can always get better with learning and practice. The same is true with coping with chronic pain. No matter where you are on the spectrum of coping with pain, you can always get better at it.

Looking at coping in this way takes the judgment out of it. You don’t have to feel bad if there is more for you to learn about how to cope with chronic pain. Everyone, no matter who you are, can learn how to cope with pain better. In reality, it’s true of coping with whatever problem you face. There is simply no endpoint at which someone knows all there is to know about how to cope with the problems they have.

Let’s, then, look at what people do when they cope really well with chronic pain. Research psychologists spend a lot of time studying how people cope with adversity of any kind. Clinical and health psychologists spend a lot of time teaching patients how to overcome adversity. Based on this research and clinical experience, we might review a number of skills and attributes of people who cope well. The point here is that it is a learning process. Just like the guitar player who studies superstar guitar players by listening to them and trying to do what they do, let’s review the skills and attributes of people who cope really well with chronic pain. By doing so, you learn from them and can practice doing what they do.

As we do, try not to feel bad about yourself if you don’t do exactly what they do. Remember the point about the spectrum of coping with pain: coping is a set of skills and no matter how well (or not-so-well) you cope with chronic pain, you can always get better at it. It’s true for everyone. So, don’t feel bad if you can learn a thing or two. Everyone is in the same boat as you are. (In fact, rather than feeling bad about it, celebrate it! Isn’t it great that you can learn to cope better with pain!)

There are almost countless ways to get better at coping with chronic pain. In this post, we will review five of them. We will then review five more in the following post. The intention is for these posts to be a series that reoccurs on a periodic basis.

Skills and attributes of those who cope with chronic pain really well

1. They are open to change and learning from others.

People who cope with pain really well are open to change. They recognize that things will have to be different now that they have chronic pain. In this way, they are flexible and adaptable. They do not insist on returning to exactly how they were the day before they were injured or became ill. They recognize and accept that doing so would be impossible. Rather, they are open to new ways of living. They adapt their work positions or even seek out new employment positions that work well with their chronic pain condition. They find new social and recreational activities. If it hurts too much to stay in the bowling league, they join a cribbage league instead. They also find new ways to stay involved in their religious or civic organizations. Because they are open to change, they might still work or still have fun with their friends and family and are still engaged in their community, despite the chronic pain.

People who cope well with chronic pain are also open to learning from others. They don’t get offended or defensive or nervous when talking about how they might come to learn better ways to cope. Rather, they acknowledge that they don’t know everything there is to know about coping with pain. They also recognize that there is no shame in learning new ways. Like we did with the discussion above on the spectrum of coping, they understand that they can learn a thing or two and don’t feel bad about it.

2. People who cope really well with chronic pain accept that their pain is chronic.

Initially, it might seem counter-intuitive to accept that your pain is chronic. Understandably, many patients want to maintain hope by trying to find the right specialist who can cure them of their chronic pain. At some point, though, it’s helpful for most patients to recognize that medical management has its limits. Why? Because when your pain is truly chronic, it means that it is not curable. Chronic health conditions are conditions for which we have no cures and for which the patient will have to live with. Insistence on finding a cure long after it is reasonable to recognize that your pain as chronic becomes itself a problem. It can reduce your ability to cope because it leads to a vicious cycle of false hope in a cure that never comes followed by failed treatment and then disappointment. Hope and disappointment is a common theme as patients talk about what they have tried when attempting to cure their pain – the various medications, injections, and surgeries they have tried. If this cycle continues for too long, patients come to feel hopeless and depressed.

So, at some point, it is helpful to accept the chronicity of chronic pain. People who cope really well with chronic pain do it. They don’t spend time trying to fix what is ultimately an unfixable problem. They recognize it would be a losing battle and that it would lead to becoming hopeless and depressed.

3. Instead, people who cope really well with chronic pain focus on what they can do to manage their pain.

They seek out things that they can do to manage pain rather than looking to other people or other things to manage their pain for them. They don’t see ‘pain management’ as something that their healthcare providers do or that their medications do. Rather, they see that the lion share of it is their ability and responsibility.

They have a routine of ways to self-manage their daily level of pain. When they have a typical pain flare, they ask themselves what’s going on in their lives that might be contributing to it and then set about to resolve it. In short, they consider themselves to be primarily responsible for their health in general, not their healthcare providers.

This point is true of all people who cope well with any chronic health condition. The person who copes well with heart disease is typically one who doesn’t primarily rely on healthcare providers to manage the disease for them. Rather, one who manages heart disease well is one who quits smoking, engages in regular exercise, changes their diet, loses weight, and manages stress. Of course, they might see healthcare providers too. However, it is a matter of emphasis.

People who manage chronic health conditions well are those who primarily see their health as their responsibility and so rely on their healthcare providers less, rather more.

This emphasis on what the patient can do is called empowerment. People who cope with pain really well feel empowered and confident in self-managing their chronic pain. They know what their pain is. They are not alarmed by it. They know what to do about it. And they do it.

4. People who cope with pain really well exercise on a regular basis.

Typically, they engage in a low-impact, mild aerobic exercise at least three to four times per week. Examples are walking in a pool, walking outside or on a treadmill, riding a stationary exercise bicycle, or using a stationary arm bike. All these exercises involve a low degree of impact to the body. However, they all are aerobic, or cardiovascular, exercises. That is, they get your heart rate up.

The importance of a mild aerobic exercise is its effect on the nervous system. Following an aerobic exercise in which you get your heart rate up for a period of time, the nervous system relaxes. You feel grounded. You have a sense of well-being. It’s why people exercise to manage stress. Runners call it ‘a runner’s high.’ However, you don’t have to run in order get it. The exercises listed above will do just fine.

Why is this important and why is it helpful? It’s because chronic pain is a nervous system condition. Whatever the initial cause of your pain, if you have chronic pain, then you have a nervous system that is stuck in a persistent state of reactivity, making the nerves super-sensitive. Any little movement sets the nerves off firing pain signals to the brain. People who successfully self-manage chronic pain maintain their nervous system reactivity in the lowest possible state. One of the many ways to do this is to engage in a regular, low-impact aerobic exercise.

Following each time you engage in an aerobic exercise, your nervous system relaxes for a period of time. Of course, since you have chronic pain, it returns to a higher level of reactivity after awhile. However, if you do it again and again, on a regular basis over time, your nervous system returns to lower and lower levels of heightened reactivity. In effect, you are down-regulating the reactivity of your nervous system. As such, you have less pain and more ability to cope.

Also, regular aerobic exercise improves your mood. Again, many people exercise solely for its stress-relieving properties. When we engage in an aerobic exercise, we feel good, not only physically, but emotionally too. When you exercise on a repetitive basis, your mood gets better and better. Consequently, when your mood improves, you cope better with the chronic pain that remains.

For both of these reasons, people who cope with pain really well almost always engage in a low-impact, mild aerobic exercise on a regular basis.

(Let me make two quick notes before moving on. First, you should always check with your healthcare provider before starting an exercise routine for the first time. Chances are, they will be quite supportive of the idea. However, some people might have medical conditions that can complicate matters and for which you need specific instructions for your specific condition(s). Second, many healthcare providers continue to treat chronic pain as if it is the result of a long-lasting acute injury. They subsequently recommend stretching and core strengthening exercises. These might be helpful, especially if you are out of shape and would find walking, for instance, too difficult. However, their effectiveness for chronic pain is limited. They are best seen as a way to get you into enough shape that you could then transition to a low-impact, mild aerobic exercise. They are like a bridging exercise to get you to your goal exercise.  In and of themselves, you probably don’t want to expect a lot of improvement in pain or coping from them. Improvement comes when you are able to engage in a mild aerobic exercise over time. )

5. People who cope really well with chronic pain understand the relationship between pain and stress.

They understand that they have to keep their nervous system in check. They understand that whatever affects the nervous system also affects pain levels. Moreover, they understand that stress affects the nervous system. They subsequently use this knowledge to help them cope with pain: one of the chief ways to manage chronic pain well is to manage stress well.

People who cope with pain really well see life’s problems in terms of their stressful impact and how these stressful problems make their pain worse. They see such problems and automatically assume that the stress of them affects their pain levels. Any of life’s problem can be stressful, of course, but some examples are you and your spouse not getting along, your kid getting into trouble, a period of insomnia, getting behind on bills, or the loss of a loved one. People who are coping with pain really well take it for granted that these kinds of problems make their pain worse.

This knowledge allows them to cope with pain well in two different ways. First, they understand that their pain levels are in some ways a barometer of what else is going on in their life. They always have, of course, some baseline level of pain from the pain condition they have. However, what makes their pain wax and wane beyond the normal level of pain is how much stress they are experiencing. If their pain is through the roof one day, they ask themselves what else is going on. They subsequently identify the stressful problem and set about working on it. By resolving the problem, they reduce their pain back down to their normal level of chronic pain. In this way, managing stress is a way of managing pain. Second, by knowing the relationship between pain and stress, they don’t become alarmed when experiencing a pain flare. They don’t, for instance, think that their underlying health problem is worsening or they don’t think it is necessarily cause for seeking repeat diagnostic testing. They know what it is and can identify where it is coming from. They know that it is a stress-induced pain flare. Then, they set about trying to resolve the stressful problem and reducing the reactivity of their nervous system.

In these ways, they remain grounded, empowered, and in control. These are attributes of those who are coping with pain really well.

For more information, please see the next post in the coping with pain series here.

Author: Murray J. McAllister, Psy.D.

Date of last modification: April 21, 2014

5 Benefits of a Chronic Pain Rehabilitation Program: A Patient’s Perspective

The Institute for Chronic Pain (ICP) would like to welcome a guest post by Jen of Pain Camp. Camper Jen, as she goes by, is the founder of Pain Camp, which is a wonderful blog and website on chronic pain from the perspective of someone who has chronic pain and has participated in a chronic pain rehabilitation program. Her site, as well as her personal story, is one of how to go from SURVIVING to THRIVING despite having chronic pain. Her spirit is admirable and her testimony is inspiring. Her guest blog post today is on her experience of the benefits of participating in a chronic pain rehabilitation program.

The ICP hopes that you check out Pain Camp. It’s well worth it. In fact, it has recently been nominated for 2013 National Association of Social Workers Media Awards for best website category.

Here’s the guest blog:

5 Benefits of a Chronic Pain Rehabilitation Program: A Patient’s Perspective

I was 35 years old and sitting in my primary care physician’s office complaining of terrible headaches and neck pain. I’d been afflicted with the pain for over a month and there was no improvement despite chiropractic treatment and massage (unlike the times before). I felt like my doctor was not listening to me at all. In tears, I begged for an explanation. Why wasn’t the pain going away this time? What was wrong with me?

I was diagnosed with chronic pain syndrome. It was March of 2011. For the following six months, I visited many different doctors and participated in many different types of “therapy.” I had several tests, procedures and medication trials. I was not getting any better. In fact, I was only getting worse, and I had the additional diagnoses to prove it.

After six months of that chaos, I was ready to explore another approach. I had already worked with the interventional pain specialists; opioids were not an option (I’m in recovery); and the majority of my pain related diagnoses would not be improved with surgery at that point in time. The only other thing to try was a chronic pain rehabilitation program (CPRP).

The particular CPRP that I went to was a 3 week-long program. There were eight patients in the program that stayed during the week and went home on the weekends. From the second I entered the facility, I was challenged. I was also given incredible gifts. Here are five of the most valuable benefits from my experience:

1. I’m not a victim!

I struggled over the first few days with the structure. Despite having severe pain, I was expected to participate in daily pool therapy, exercise in the gym 3x/week, and get to classes (on time). It was clear that staff was not there to pity me, and the environment at the rehab facility was not one that supported a defeatist attitude.

I was not feeling validated in my self-pity so I met with the Clinical Director. She gave me a challenge that turned my perspective around. I was indeed allowed to feel my emotions and be upset (validation). However, I needed to put a time limit on them. I could allow myself a 30-minute emotional meltdown if I needed it and then figure out action steps to move on.

From that point on, I was more open to the information that I was learning in class. I became an empowered patient rather than one that was helplessly clinging to any hope of a “cure”. Yes, I had Chronic Pain. Yes, it wasn’t a fair situation. And yes, I still needed to figure out how to live my life partnering with the pain rather than working against it.

2. I’m not alone!

One of my fears going into the program was that I wouldn’t have anything in common with the other patients. I was younger and well-educated with a professional career. To my surprise, I did have those things in common with some of the other patients. Even more comforting was spending entire days and evenings with people who were just like me. They understood chronic pain from my perspective. They’d had life changes because of the pain. They were at a point of acceptance and ready to make changes like I was. We were all in the same boat.

The staff told us that they did follow up with the patients many years later. One common theme among the CPRP patients, even many years later, was that creating relationships with the other people in the CPRP was one of the most beneficial points. I would have to agree as I formed two very solid friendships during my time at the CPRP. I still get together with these two women. They understand my pain and they do not judge me. We positively support and encourage one another on the most challenging days. These two friendships were an unexpected and invaluable benefit from the CPRP.

3. I can function!

Before I was admitted to the CPRP, I was going to four to six doctor appointments a week and trying to hold my full-time job. I’d already resigned from my part-time position. I’d given up all hope that I would ever be able to engage in: exercise, housework, cooking, family activities, spending time with friends. These were just extra tasks that I couldn’t afford energy-wise. I was miserable. The CPRP taught me that I didn’t need to be afraid of exercising. I also learned proper body mechanics for household tasks. I was reminded of the importance of humor and how spending time with my friends again could aid in healing.

4. I will pace!

I have been told that I have a “Type A Personality.” Even with the pain, I was still trying to run my life at the pace of the hare. God help you if you were a turtle trying to slow me down. Over-achiever and giving 100% of my all to every activity in life. In the CPRP, I learned that by holding onto this harried lifestyle, I was making my Chronic Pain situation worse.

In the CPRP I learned it is crucial that I pace and conserve my energy. I have my days when I feel “well” (as well as can be) and then I have my more challenging days. On my “well” days, I need to be mindful of pacing so that I do not overdo things. Energy conservation is the key. On the more challenging days, I need to be mindful of resting and formulating a plan of action to resume activities. This requires more structure in my life and scheduling periods of rest and healing activities. These are things that I didn’t have prior to the CPRP. Making sure I get enough sleep, proper nutrition and restorative yoga is also part of my pacing routine.

5. I have hope!

When I entered into the CPRP, I was hopeless. I didn’t think that my situation could improve. I was depressed. I was anxious. I was full of fear. By participating in the CPRP, I was shown that there is another way of life for those with chronic pain. Yes, my life would be different and would have to change. However, the CPRP taught me that I was in charge of managing this new life.

Of course, there was a process of grieving my old lifestyle. I also had to grieve the loss of my dream to be able to work 60 hours a week, pay off my school loans and retire at the young age of 60. By grieving these losses, I was able to formulate new goals and dreams. I was able to develop hope that I would be okay with my “new” life with chronic pain by my side. I gained hope and that hope continues to grow every day.

While participating in a CPRP was certainly not on my life’s agenda, it was definitely a gift that was given to me. I am grateful that I was able to participate in a CPRP. I learned that I was not helpless, nor was I alone. I was challenged to develop new skills for living my life with chronic pain. I was given a basic set of tools to move from surviving to thriving.

It is my hope that one day the CPRP is the first stop in the patient’s care plan for Chronic Pain, rather than the last. I believe that the CPRP is what offers the most benefit to patients with chronic pain and can get us back to a level of functioning that is productive and has meaning.

Author: Camper Jen of Pain Camp

Date of Last Modification: 2/22/2013

Are you ready for a chronic pain rehabilitation program?

How do you know if you are ready to participate in a chronic pain rehabilitation program?

Chronic pain rehabilitation programs defined

Chronic pain rehabilitation programs are a traditional form of chronic pain management. They are intensive, interdisciplinary therapies that typically occur on a daily basis. They coach patients how to self-manage chronic pain and the common secondary stressors that result from pain, such as insomnia, depression, anxiety and stress. They also help patients return to work. Lastly, they help patients to reduce the need for on-going healthcare services for chronic pain.

Criteria for participating in a chronic pain rehabilitation program

Healthcare providers typically use three criteria to determine whether a patient is a good candidate for a chronic pain rehabilitation program. The criteria are the following:

  • Noncancer pain lasting longer than six months
  • All reasonable medical options for the treatment of the pain have been exhausted
  • The patient accepts that his or her pain is truly chronic and needs to learn how to self-manage chronic pain

The third one is the kicker. The vast majority of patients referred to chronic pain rehabilitation programs have chronic pain and have exhausted all reasonable options for their pain disorder. Their providers know it and the patients tend to know it too. It’s easy for both providers and patients to know when pain is chronic. It’s lasted longer than six months, usually for years. However, knowing that pain is chronic is different from accepting that pain is chronic.

Accepting that chronic pain is really chronic

Unlike their healthcare providers, patients with chronic pain face the challenge of accepting the chronicity of their pain. Acceptance is an emotional process that patients go through when having chronic pain.

For many patients, the initial phase of acceptance is fraught with refusals to accept it. ‘There just simply has to be a way to fix this problem,’ one might say at this point. As such, patients commonly continue to seek evaluation and care from specialist after specialist in attempts to find a cure for their pain disorder. At this point in the process of acceptance, the underlying belief is that hope lies in finding a cure and that without a cure there is no hope. Given this belief, it makes sense that patients might know that they have chronic pain (in the sense that they know it is lasting a long time, maybe even years), but yet refuse to accept that their pain is truly chronic (in the sense that there is no cure). For if the belief is that the only way to have hope is to find a cure, then to give up hope of a cure is tantamount to becoming despondent. Hopelessness is a powerful motivator that fuels on-going refusals to give up hope in a cure.

When patients are at this point in the process of acceptance, they are not yet ready for a chronic pain rehabilitation program. They typically don’t succeed in learning to successfully self-manage chronic pain because their motivation lies elsewhere. Namely, their hope lies in finding a cure. They haven’t yet accepted that their chronic pain is truly chronic. They haven’t yet found a new way to have hope.

This observation is not a criticism. It’s just that such patients don’t meet criteria for being a candidate for a chronic pain rehabilitation program. They have not fully accepted the chronicity of their pain and instead they prefer to seek care other than self-management or rehabilitation.

Accepting that you can’t manage pain with opioids for the rest of your life

Difficulties with accepting the need to self-manage pain without opioid medications is another common struggle that gets in the way of participating in a chronic pain rehabilitation program. Many patients have worked through the afore-mentioned problems with accepting that there is no cure, but have found hope through long-term opioid management. They recognize that they have chronic pain and that chronic really means chronic. Nonetheless, they have kept from becoming hopeless by managing their pain with the long-term use of opioid pain medications. As such, they have been able to go on with life even in the absence of a cure.

Some patients in this position recognize that their long-term use of opioid medications is not sustainable indefinitely. They recognize that the medications lose their effectiveness over time. They have increased their dose at different times, but with each increase in their dose, they have eventually become tolerant yet again. They recognize that they can’t periodically increase their dose indefinitely. As such, they understand that the use of such medications cannot be a viable long-term way to manage pain.

This problem of opioid medications becoming ineffective over time is called tolerance.

It too is a difficult problem to accept. It is common for patients to struggle with accepting that the long-term use of opioid medications won’t be effective indefinitely. The implication is that at some point patients will need to learn how to self-manage pain without the use of such medications. Patients commonly struggle to accept that need too. It’s easy to put these problems off and deal with them another day. In other words, it’s easy to refrain from accepting them.

When patients aren’t at a point of accepting that they need to do something about these problems, they aren’t ready to participate in a chronic pain rehabilitation program. They oftentimes don’t believe it is possible to successfully self-manage chronic pain without the use of opioid medications. As such, they don’t succeed in learning how to do it in a chronic pain rehabilitation program.

This observation too is not a criticism. It’s just that such patients don’t meet criteria for being a candidate for a chronic pain rehabilitation program when they have not fully accepted the chronicity of pain and their need to self-manage it.

Acceptance of the need to learn how to self-manage pain

Patients are good candidates for participating in a chronic pain rehabilitation program when they accept both. They accept the chronicity of their pain and the need to learn to self-manage their pain. Of course, they don’t know how to successfully self-manage pain yet, but they have reached a sufficient degree of acceptance that they are ready to learn. As a result, they seek out participation in a chronic pain rehabilitation program and often succeed in their goals – to be able to live well, engage in life and work, while at the same time managing their chronic pain at tolerable levels.

Accepting the chronicity of pain opens up a whole new way of getting better and a whole new way of having hope.

Authored by Murray J. McAllister, PsyD

Posted on 2/4/2013