1. Obese, type 2 Diabetic: reasonable control. Pain 3 months both knees crippling XR early degenerative changes only. 3 weeks sick leave- work wont consider early retirement. Has meeting with boss next week- feels boss is not understanding You wonder whether patient is depressed... What is the greatest challenge here? Mr J F 54 year old Museum Guide

2. Ideas: I Have OA. I cant walk –walking makes the pain worse. When the pain gets worse this means I am destroying my joints. Concerns: I am time expired- my working life is over as there is no way I can work with my condition. I will be unable to support my family. I will lose my pension, standard of living, self esteem, my status. Expectations: the doctor cant do anything to change this. I dont want surgery, I dont want pain killers. Physiotherapy is painful therefore wont help. Manage ICE

3. A Standard CBT Approach Activity Moods and Emotions Pain and other Sensations Thoughts and Beliefs

4. A Standard CBT Approach Activity Moods / Emotions Sensations Thoughts

5. Challenging negativity Nothing I can do makes any difference

6. Worked example 2 Pacing

7. Sally is a 34 year old single mum- With 2 children, Joel (7) Esther (3) Sally slipped and fell on wet floor 9 months ago at work –unable to return since due to pain in her back. GP told her to rest 2w- then refd for XR and physio.

8. 3w later Xray report said no abnormality detected Sally was confused as pain was getting worse not better. GP sent her for a scan but 6m wait. Sally takes 8PCT/day only takes edge off the pain Physio told her to get moving more, gave her US therapy (which hurt) and exercises (which hurt more) so she stopped going...

9. Luckily Sallys parents lived close by and helped all they could- shopping, cooking, cleaning, getting Joel ready for school, taking him and picking him up. Esther spent all day with her grandparents leaving Sally to get as much rest as possible. She frequently spent whole days in bed.

10. Pacing: Can you identify what style of pacing Sally uses:

11. Advantages to this approach What are the possible advantages for Sally pacing this way?

12. Advantages Gets a great deal of help Reduces the degree of pain she experiences Reduces the likelihood that the underlying cause of the pain will progress Gives validity to the pain Gets compensation / DLA – And the disadvantages:

13. Disadvantages Collusion Catastrophisation (extreme of negative thinking) Fear avoidance Becomes dependant (learned helplessness) Reduced self esteem Reduces amount of control Learned helplessness Guilt feelings Misses out on children Socially isolated Reduces conditioning Increasing obesity Living day by day - no forwards planning

14. BLOCKS to effective pacing. What are the blocks preventing Sally from pacing more effectively?

15. Self management is the key… What skills would you advise her to try out?

16. Learned Skills for managing chronic pain 3 Ps – Plan daily routine – Prioritise activities / tasks – Pace activities.

18. What kind of pacing? What kind of Pacing?