1. Returning to Function Part Two Box Breathing

3. Setting Functional Goals

4. 4  The purpose of pain is not to accurately tell us: › where the problem is › what the problem is › how bad the problem is  Pain’s job is to make us stop!  Our patient’s need treatment and guidance to make these protective responses less sensitive.  Wind down the nervous system Review

5. 5  38 year old woman  Neck pain and headaches and unable to work  Not improving 5 weeks after whiplash injury  Xrays show degenerative changes throughout lower cervical spine, with C4-5 reported as having more arthritic changes. Case Study 1

6. 6  This type of pain you are experiencing is chronic pain... but that doesn’t mean it will always be like this, or that it will continue to worsen.  Pain can be changed, and my job is to help you with that.  This medication I am giving you should make you feel that the pain is in control, and it should help you move better. I want to see you back here next week to make certain it is working for both things.  You showed me how much you can move your neck and arms today and we will recheck that next week. Scripts 1 There is hope, and, finding ease of movement is the first step.

7. 7  The medication helps to decrease pain temporarily, but her movement is no better.  When you ask her to move, she holds her breath, and tenses her neck, shoulder and face muscles.  “Close your eyes and breathe as calmly as you can for the next minute.” After a minute passes, “now try those movements again.  “remember that your protective systems are on high alert. It will be difficult to calm them down if you hold your breath and tense up so much every time you move.”  “It’s important to stop sending the message that movement is really dangerous.” Script 2 - same patient one week later Calm breathing decreases pain and helps move with more ease.

8. 8  48 year old construction worker  Slow to resolve low back pain and right leg nerve root irritation pain (seems L5 distribution but no conduction deficits)  MRI 8 weeks after a lifting injury shows L4- 5 lateral disc bulge, central stenosis and osteoarthritic changes Case Study 2

9. 9  Patient asks - “What can you do to fix this?”  “You have a problem in your back, and irritated nerves. The best treatment we can do is to work on calming down the irritation.  Your job in this plan is to spend time every day relaxing and getting your body and breathing to feel as calm as possible.” – (we do not know the best dose of this, so fit it into the patient’s day)  “The job of this medication is to let you move more easily. If it is not doing that, we need to try something else.” Scripts 3 Brief description of chronic pain, and the roles of relaxation and medication.

10. 10  43 year old woman with fibromyalgia  Previously high-level, high-paid executive position  Unwilling to try medications until now  Exercise has made her worse  Meditation and sitting still make her more anxious Case Study 3

11. 11  I am pleased you are ready to try some things other than just being tough and trying to win a battle with this pain.  We know that in fibromyalgia many aspects of the nervous systems are cranky and over-sensitive.  Our job, together, is to find ways to calm them down again. It’s not easy, but it’s possible.  The medication we are trying should let you move with less pain. The yoga you are doing should also help with that.  Remember that the strength you have to be tough and carry on in the face of this pain is not helping you get better. Somehow you need to stay tough, but don’t push so hard.  You need to pay more attention to your body and pain, not less. Scripts 4 Brief explanation of fibromyalgia pain, and why initial attempts at what should help are sometimes unsuccessful.

12. 12  64 year old active employed male  10 weeks post TKA, and his pain and function are worsening  He is angry, believing that the pain must be from faulty surgical technique and that the surgeon is saying he is making this pain up  Orthopaedic surgeon has investigated and the prosthesis is not the problem Case Study 4

13. 13  “When pain persists like this and we cannot find the reason for it from the tissue or the surgery, we know that the problem includes unexpected responses from the pain system.  This is something you need to learn much more about so we can work together to help you out. Here is a link to the Pain BC webinars where they talk about this in much more detail, and it would help to read this book... you can get it from the library. We will need to talk some more about this, because it will sound different from what we have discussed before.” Scripts 5 Post-surgical pain can be related to sensitization and wind-up. Pain education is often the first step needed in such cases.

14. 14  “Your pain is real. It may not be easy to change it, but we can.  This medication is to help you move better, and not pay for it so much.  Your nervous systems have become far too agitated - by the pain before the surgery, and all the stress after it. I want you to see this counsellor to learn breathing and relaxation techniques. And I will contact your physiotherapist to make certain she is getting you to do as much work on calming down the nerves in your knee as working on getting you stronger.  If we all work together we can help you best with this.” Scripts 6 Reassuring the person in pain that we know what to do, and, providing the understanding that a team approach is needed.

15. 15  www.painbc.ca www.painbc.ca › Empowering Self Management of Pain series › The Pain Toolkit › Yoga for People in Pain series  Chronic Pain Self-Management Program (University of Victoria)  Understand Pain, Live Well Again Pearson, N. Patient education book available in all BC public libraries  Explain Pain Butler D, Moseley L. www.noigroup.comwww.noigroup.com  http://www.physicalactivityline.com/ http://www.physicalactivityline.com/ Resources

16. 16  MH algorithm (http://www.gpscbc.ca/psp-learning/mental- health/tools-resources)http://www.gpscbc.ca/psp-learning/mental- health/tools-resources  CBIS from PSP’s adult mental health module CBIS  Problem list Problem list  Resource list  Brief Action Planning Brief Action Planning  Bounce back DVD Bounce back DVD  Anti-depressant skills workbook Anti-depressant skills workbook Practice Support Program Tools