1. Department of Pain Medicine
Persistent Pain
Dr A. Erdmann, Consultant in Pain Medicine
R.Hayward, Clinical Specialist Physiotherapist
P.Wilkinson, Clinical Specialist Occupational Therapist

2. From the floor
What are the challenges for you when seeing people with persistent pain?
Any themes/topics to cover in this part of the session?

3. In brief Exploration about what we do and how we do it
The issue of acceptance and change
Resources to use with patients
In brief

4. What is it like having persistent pain?
Ask the question – difficult consultation – what did the person say? How did you feel afterwards?
Impact of pain – chronicity, uninvited guest
Association between stress, distress and pain is bidirectional
What is it like having persistent pain?

5. https://www.youtube.com/watch?v=ZUXP qphwp2U
Pain and me

6. Sheffield Persistent Pain, 2019

7. Pain is complex and a multi-system experience (biopsychosocial)
People rarely present with just one issue when pain involved
Peoples’ strategies often work short term, but make the situation worse long term.
What we all know…

8. Case study -fibromyalgia
What other information would you like to ask Susan?
What else would you like to include as part of your assessment?
How would you formulate this case?
What may be part of your intervention?
Case study -fibromyalgia

9. Group feedback/discussion
Your ideas

10. How Do You Deal With Pain Now?
Swing between the two
Resign to it (feel overwhelmed
and don’t know where to start)
Resist it (ignore the pain– keep going or pushing through)

11. Information on Condition Family/Work Circumstances
Other factors
Past experiences
Information on Condition
Family/Work Circumstances
Think
If I start a job I need to finish it
I have to…. / I should……
Others expects me to…
Others don’t understand
It’s my job….
Feel
Anxious
Guilty
Stressed
Frustrated
Angry
Sad,depressed
Physical Sensations & Symptoms
Muscle tension
Increase in Pain & Fatigue
Reduced fitness
Adaptive movement
Sensitisation of the nervous system
Do…Behaviours
Pushing through pain
Rushing / not taking breaks
Saying ‘yes’ / not saying ‘no’
Ignoring your pain,
Taking more medication
Catching up on a better day
Unawareness of fitness – trying things
unfit for
Using the body in a changed way
Avoiding normal movement
Not communicating to others
Resign to it (feel overwhelmed) Resist it (ignore it – keep going)

12. Information on Condition Family/Work Circumstances
Other Factors
Past Experiences
Information on Condition
Family/Work Circumstances
Think
If I do… it will ↑ pain & damage
There’s something seriously wrong
I can’t…..
Others don’t understand…
Feel
Anxious
Guilty
Stressed
Frustrated
Angry
Sad…low….depressed
Physical sensations & Symptoms
Muscle tension
Increase in Pain & Fatigue
Reduced fitness
Adaptive movement
Sensitisation of the nervous system
Do…Behaviours
Spending lots of time inactive
Lying down a lot / staying in bed
Taking long rests
Avoiding activities of daily living/personal care
Watching out for the pain
Unawareness of fitness
Using the body in a changed way
Avoiding normal movement
Not communicating to others
Resign to it (feel overwhelmed) Resist it (ignore it) keep going)

13. So what does this help us with?
Helps the person make the links between their thoughts, feelings, emotions, behaviour and physiological state.
Offers the person and us a way in to help examine thoughts as useful/helpful… OR NOT!
Provides the person with increased insight regarding choice/control in relation to their behavioural responses.
Can develop ways to manage physiological responses too, to reduce these. E.g. breathing techniques.
Work with what the person wants to address – their functional goals

14. Pain Management -What we aim to do
1) Education, (understanding) commonality, reassurance, relevance of self-management (shift from biomedical model to the biopsychosocial)
2) Validate pain experience, believe, space to tell story (alliance, co-partnership approach)
3) Establish what could change, goals, motivate, sow seeds of hope (acceptance)
4) Assistance with change – targeted therapy interventions
No one size fits all solution, and non linear process

15. Process of Change
The relationship blog, 2018

16. Susan’s road to recovery
Focus on recovery plans
Doing things important to you & moving towards goals
Managing stress & building up coping skills
Improving confidence with self management strategies
Being open to new ideas
Being clear about your current limitations
Establishing manageable activity levels
Balancing activity, rest, sleep with pacing strategies
Building fitness with graded activity & exercise
Increasing activity
MIND
BODY
Susan’s road to recovery

17. MDT -Different professional roles in team
Clinical specialist nurses x2
Clinical Specialist Occupational therapist
Clinical specialist Physiotherapist(s)
Consultant Clinical Psychologist
Consultants in Pain Medicine
Administrative support
MDT -Different professional roles in team

18. What can we offer help with?

19. Physiotherapy- Increasing Activity Despite Pain
Awareness around adaptive movements
Restore “optimal” movement patterns
Exercise prescription
Pacing exercise
Managing muscle tension
Flare up management
Signposting to community exercise schemes
Physiotherapy- Increasing Activity Despite Pain

20. Occupational therapy – the doing stuff of life
Emphasis on occupational functioning in key roles
Assessment covers self-care, leisure and productivity occupations
Agreeing occupational goals for change is crucial
Will, Skill and Drill
Vocational specialist – staying in, getting back to work.
Occupational therapy – the doing stuff of life

22. Difficulty
Recommendations/goals
Link difficulties to occupational performance issues

23. Lightbulb moments in therapy/consultations
Finding the bridge
Establishing what matters to the person
Despite the pain, what do they want to get back to doing?
Promoting agency in recovery
Lightbulb moments in therapy/consultations

24. Use metaphors about being stuck and making decision to change
Ask about previous LIFE - tough issues and how they coped
Recognise that staying stuck is an option but one with consequences
Encourage person to talk about what they see these as the smallest goal to them
Cheerlead, validate any positives
Moving forward?

25. Explain Pain – D.Butler &L.Moseley Neuro orthopaedic Institute
Look on Youtube for some of Lorimer’s lectures regarding pain.
Research shows that clinicians often underestimate what patients can understand regarding their pain and the science behind it.

26. Books

27. Resources
Understanding Pain in less than 5 minutes and what to do about it.
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Ted talk –Lorimer Mosely-Why Things Hurt
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28. Pain Resources
Using different media can help with engagement and insight.