Pain Coach Workshop for GPs

Why should GPs understand pain?

Audience Applaud Clapping Happines Appreciation Training Concept

Sat 3rd June Education Morning at New Malden Diagnostics Centre

~ Do you understand pain?

Can you confidently answer these questions:

  • what is pain?
  • what do we currently know about the causes of pain?
  • what can the person in pain do to overcome their pain?

Pain is one of the commonest reasons to seek help. And we are not only talking about back pain or neck pain, instead thinking about all the circumstances and conditions that feature pain. Digging deeper, whilst the pain is unpleasant by its very nature, it is the suffering that drives the act of going to the doctor. We can even take this a stage further and suggest that the causes of suffering result in consulting with the GP. For example, the person who cannot work, cannot play with their children, cannot play sports etc. It appears as if life’s choices have disappeared. By definition, suffering refers to the loss of sense of self, and indeed the person with persistent or chronic pain can feel such loss.

The existing understanding of pain has taken us a long way away from the biomedical model. The biopsychosocial model has gained some traction but the predominant approach continues to be driven by the search for an injury, a pathology or a structural explanation. For many years it has been known that pain and injury are not synonymous ~ the famous paper by Pat Wall was published in 1979:

“The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.

Pain features when we are in a state of protect in the face of a perceived threat. The intensity of the pain relates to this state and not to the extent of tissue damage. Pain and injury are fundamentally different and hence any explanation or treatment for pain based upon the thinking that a ‘structure’ or biomechanics is to blame is at odds with our understanding of pain. In fact, it is this misunderstanding that contributes significantly to chronic pain being the number one global health burden. This can and must change, which is the raison d’être for UP | understand pain.

~ understand pain to change pain

This being the case, this workshop will be a brief look at this enormous societal issue, a public health concern of vast importance considering the massive costs and immeasurable suffering. Not only will we review current thinking and understanding, we will consider the role of the GP and practices that can be readily used.

  • understand pain yourself
  • know your role
  • how can you help the person understand their pain?
  • setting the person on the right course: what is their vision of success?
  • practices you can choose to use in clinic

This overview is based on the Pain Coach Programme. The programme delivers results for people who make the decision to commit to practices that bring about change in a desired direction. They understand that we are designed to change and that we have great potential to be harnessed and used to overcome pain and live a meaningful life.

1:1 Pain Coach Mentoring: for clinicians who choose to pursue understanding pain to a greater level together with the practice of Pain Coaching.

RS

A life of appointments

When life is dominated by the next appointment


Most people I see have a long story of pain. Frequently there has been years of suffering that has and does impact upon their life.  For some their days are strung together by appointment after appointment as they search for an answer to their pain. The key that unlocks that door is understanding pain. To understand pain is to know what you can do to move onward in a chosen direction. Undoubtedly, we can be successful in overcoming pain because it can and does change. We are constantly changing, like the water of a river, there is constant movement in one direction. Embracing and harnessing our potential enables us to live a meaningful life.

Whilst seeking an answer, there are always boundless doctors and therapists who offer solutions. Skipping the understanding bit and hastening to a remedy or treatment is often the way, yet the foundation is not in place. We must understand our pain to gain a sense of meaning, to know that we need not fear pain and instead to focus on certain practices and skills to enable change.

Expectations are typically low in chronic pain, which affect outcomes. The promise of success followed by yet another failure hits hard. Some people even blame themselves as the self-critic chips in. Developing self-compassion is a key skill as we learn to be patient with ourselves, let go of blame and focus on living well. To be harsh towards oneself is to provoke the same biological protection as when we feel pain. Of course our expectations are based on what we know, past experience and in the moment adjudication of the likelihood the treatment will work (based on what we already know again). In essence it is a prediction as is our current perception. The wonderful thing about being human is that we can change the prediction and infer something else. It is time to expect to get better. To expect that life will be full of challenges, but to expect to face them, learn and move on in a meaningful way. This starts with understanding pain.

One of the issues with on-going appointments is that the person maintains their focus on pain in their life. There is plenty more to define the person than their pain. What we focus upon we get more of, is a loose rule. If pain becomes dominant and rents much space in our conscious capacity, then there is little room for anything else. We must make space and while we are attending appointment after appointment, no space is being carved out. But I need the appointment because I must check and see if I have…….. etc, you may say. It is true that we must elimate any serious pathology or injury that necessitates repair, but beyond that, if the focus is upon living well and practicing such skills, then getting better is possible. The roundabout of consulting rooms is not.

~ pain and injury are not synonymous 

Regular readers know that pain and injury are not synonymous. They are different. And they are poorly related. We have known that for years yet the modern approach persists in a search for a structure or pathology to explain pain. There is no such thing as pain is a body, or whole person state. Like fear, like love, like hunger. You can see none of these because they are lived phenomena, experienced by a person and embodied by a person. A herniated disc, a disc bulge, an inflamed tendon, none are pain. Pain is a state of protect that emerges in the person in the face of perceived threat. Yes, these visible changes can co-exist with pain, of course. But they are not pain and not the cause of pain. The cause of pain is a perceived threat. It is how we and our body systems (they are not separate) interpret what is going on in our body but within the context of this moment (emotional state, environment, who we are with, what we are doing, prior events etc) that determines whether we feel pain or not. You will note from this description all the opportunities we have to change pain, because pain is part of me as much as my ears or my hair so it is mine to change. The change begins with understanding pain.

So, once you have seen the relevant specialists and determined that there is no serious pathology or injury that needs repair, and it has been confirmed that this is a problem of pain, then you can focus on getting better. This is through the practice of the skills of well-being whilst maintaining a course towards your picture of success, the healthy you with purpose.

Open space in your life to live well and be inspired to reach your potential, because you can.

RS ~

We are more than a brain

Brain On The Wall

Have we gone brain mad!

There was a great step forward when the brain was considered to be part of the pain experience. The recent popularisation was in part due to the work of Lorimer Moseley who has been researching pain and delivering insights that have definitely caused a shift in thinking. However, it was Pat Wall and Ron Melzack who were the original thinkers, inspiring work in the field of pain science and medicine, with their Gate Theory of Pain (1965).

Brain explanations have captured the popular media as the ‘neuro’ tag is shunted onto the front of words to add scientific validation. We must always check to see if the claims are truly grounded in neuroscience of course. As much as we have people writing and blogging about how science pans out in real life, there are those who sift through the literature and comment critically. We are thankful for the latter as society is regularly hit with breakthrough claims that are sensationalised. How often do we then find out that these claims are unsubstantiated or they quietly go away?

When discussing pain, and this is a complex area, the brain is rightly included. The brain is certainly involved in any conscious experience as best we know, but we are more than a brain. Pain illustrates this well. However, we commonly hear experts talk about pain in the brain, or that we feel pain in the brain. This is not true.

If I am hammering and I accidentally rap the end of my finger instead of the nail, it is very likely to hurt. The pain that I feel will depend upon context. If there is someone else present and watching me, I will have a different experience compared to if I were alone. I may wish to show that I am ‘hard’ and brush it off whilst feeling the intense pain localised deep in my digit. Being alone, I may shout out and wave my hand around, grip the finger with my other hand and ask myself why I am doing this job anyway. There are many possibilities and many different influences upon that pain experience in that moment. This involves the brain, and if I happened to be wearing a portable functional brain scanner (that does not yet exist), you would be able to see activity in certain parts of the brain. These areas are not specific to pain.

There are no pain signals, pain centres in the brain, pain messages, pain nerves or anything else specific to pain. Pain is a ‘body state’ according to Wall (1979), and one that sets us up to heal and get better through motivation. We are motivated or compelled to take action. The relationship between pain and injury is poor and often non-existent, especially in chronic pain states. Pain is about protection and survival.

~ pain and injury are poorly related

Back to my finger. The message that the pain is in my brain is still out there in society. I have just hit my finger. Where do I feel it? Where is my brain? Can I feel the pain there, in my brain? Or do I feel it in my finger?

Pain emerges in the person (Thacker, personal communication) and we feel it in an area of the body deemed in need of protection. Even just in case, which is likely to be the reason for much chronic pain. The body systems that protect continue to do so in accordance with a range of influences and situations, in particular contexts. This is predicted to be ‘dangerous’ or threatening to the (whole) person and hence we experience the phenomena of protection, i.e. pain. Pain is allocated a location in the body where we feel it. The brain is involved in this projection and hence strategies and practices that target known brain mechanisms are to be encouraged. But we also need to address where it hurts and the local tissues and associated areas that adapt to the protect state.

It is the person who suffers pain, not the brain. It is a body area where we feel pain, not in the brain. The brain is involved but we do not feel things in there. Even in phantom limb pain when there is no body part, the sensation and experience of pain is felt in that space. Tissue state and existence has a minimal role, and less so as pain persists. It is about the interpretation and prediction of what the sensory information means based upon prior knowledge that determines our conscious experience.

In our drive to change the way society thinks about pain, this is one of our messages:

Pain is about the person. Let’s treat the person because when the person feels better, the pain feels better. We can change pain. We can live a meaningful life.

RS

5 ways a partner can support and encourage you

Chronic pain can be the source of huge strain upon a relationship. Partners and other people close to the suffering individual can be at a loss as to what they can do to help. Sometimes their assistance is welcomed and other times not. It can be confusing and stressful. There are many ways that a partner can help and some will be individual to those involved. Here are 5 simple ways that a partner can help:

Be an extra pair of ears and eyes

During consultations with specialists or therapists, it can be useful for a partner to come along. Beforehand you can decide upon their role. The possibilities include:

  • listening and note taking
  • offering observations about what has been happening
  • watching and learning exercises so that they can provide feedback at home
  • just being there for moral support

Sometimes having someone else in the room, even a loved one, can be distracting depending upon what is being practiced. So do discuss this with your clinician for the best outcome.

Understand pain

When your partner understands pain they will be able to further empathise and act through compassion rather than fear and worry. We do respond and are influenced by the people we are close to, meaning that if they have a working knowledge of pain they will better provide support and encouragement.

Pain can and does vary as each pain experience is as unique as each unfolding moment. Knowing that pain is related to perception of threat rather than tissue damage or injury, along with some of the main influences (e.g. emotional state, context, tiredness) helps to navigate a way forward. To overcome pain the person learns to coach themselves, making best choices in line with their picture of success. Sometimes we need help or someone to listen to us whilst making these choices.


IMG_4241

A hug

Touch is healthy, especially from a loved one. Someone recently told me about how a hug from her children relieved her pain. Why? The release of oxytocin for a starter. The feelings of compassion and love can cut through all other emotions and feelings, which is why the development of self-compassion is one of the key skills of well-being.

Sometimes a hug can be painful of course, depending on where you feel your pain. If this is the case, then simple touch somewhere else is enough. Seek to notice the good feelings that emerge in you: what do they feel like? Where do you feel them? Concentrate on them. And if you are not with that person, just imagine a hug or a loving touch. This triggers similar activity, just like when you think about that beautiful scene in nature, your body systems respond as if you are there ~ our thinking is embodied.

Practice the skills of well-being together

A good example is metta or loving kindness meditation that cultivates self-compassion. It is best to gain instruction 1:1 to start with and then use a recording as a prompt until you are familiar with the practice. Group practice is also good when the collective or community creates a soothing atmosphere in which to practice.

At home, practice metta with your partner. Doing it together, you form a bond as you spend meaningful time together. You can also practice the exercises together. These are nourishing and healthy movements with the purpose of restoring confidence as well as layering in good experiences of activity to overcome pain.

Spend time together doing something meaningful

We are designed to connect. The chemicals we release and experience as that feel-good factor, do so when we have meaningful interactions. Pain all too often appears to limit choice and our tolerance for activity. However, on thinking about what we CAN do rather than what we cannot, we begin to build and broaden the effects of choosing positive action.

Positive action is all about focusing on what we can do: e.g./ I can go for a coffee with a friend for half an hour to gain the benefits of connecting, moving, a change of scene etc. and I will concentrate on these benefits. Make some plans, working within your current tolerance level, knowing that you are safe to do so, and follow them through by keeping yourself pointed towards the picture of success*. You can then gradually build your tolerance by pushing a little with increasing confidence.

There are many other ways that a partner can be involved. The key is to communicate openly and make plans together ~ here is a great insight into communication by Thich Nhat Hanh.


* Clarifying your picture of success gives you a direction and the opportunity to check in and ask yourself: am I heading in that direction or am I being distracted?

Please note: Whilst the practices above can appear to be straightforward, you should always discuss your approaches with your healthcare professional

Pain and choice

There is one thing that pain does and that is narrow down our choices. A sense of choice has a major role in the sense of ‘me’ and who I am. Losing choice impacts upon us significantly as we feel less and less like ourselves and who we are meant to be. This is a very common description of the impact factor that I hear when listening to people enduring states of chronic pain.

Talking to people with pain as we seek to gain insight into the causes of their suffering. This provides a way to offer support, guidance and a way forward. Of course we can only move forward, but sometimes it does not feel like that! Groundhog day.

Enabling one to see their choices then, becomes a valuable and important exercise. We have many, but sometimes we just need a little help to realise and then actualise. I believe that the greatest steps are taken when this happens as the person feels empowered to steer their ship once more.

We need to know where we are going of course, a direction created by clarifying what we want as opposed to what we do not want ~ “I don’t want pain” versus “I want to live well”. Focusing upon living well motivates actions and behaviours in line with this whereas thinking about getting rid of pain keeps our attention on pain. We will only be successful, and we can be, if we have the right approach, mindset and attitude that we may have to cultivate and practice. Most I see do need to work upon these skills of attention, resilience, self-belief and determination. That is the first choice.

We can choose our approach. We can choose to engage in healthy activities. We can choose to take every opportunity to live well. We can choose to create the conditions to feel better. We can choose to have meaningful interactions. We can choose to leave some thoughts alone if they make us feel bad. We can choose to move and gradually move more as we adapt. We can choose to learn about our pain and our responses to pain, and then change them if need be. There are many choices we can make.

Of course it sounds easy when written and the doing is different. It is an experience. However, it is perfectly do-able. We are designed to change and do so every moment that passes. We can harness our potential and opportunities with simple measures, practices and skills based on new knowledge. Achieving success is with everybody’s reach although sometimes we need some help and guidance. But we can do it. This is the ethos of UP. Let us make choices to live well, create joy and face challenges with a sense of ‘I can’.

Choose ‘I can’.

 

UBER-M to overcome persistent pain

understand painPersisting pain pervades all aspects of life, thinking, feeling and doing. Pain affects decision making, with tendencies to avoid or sometimes overdo and lead to a flare up. This is very individual, and each person will have their stories to tell about fears, worries, beliefs and what they did.

The Pain Coach Programme gives the person knowledge about their pain and skills to make moment to moment decisions about what is best to think and do at any given moment. In effect, the Pain Coach is coaching the person to become their own coach! The person is with themselves at all times, and therefore needs the knowledge in order to make the best choice. And this choice is all about taking an action that takes you towards your vision of where you wish to be. Where you wish to be is in the answer to the question ‘why do I want to get better?’

One of the strategies I coach people with persistent pain is called UBER-M. Cheesy perhaps, but easily remembered. One of the first things we do in the Pain Coach Programme is to help the person understand their pain, this to reduce fear and increase engagement with what needs to be done to overcome pain. You cannot solve a problem unless you understand it. But it is not just telling the person about their pain, it must be a working knowledge that can be applied: what do I know, what can I do now that is wise and healthy? This is the ‘U’. And below are the others:

U – understand your pain

B – breathe (mindfulness, relaxation)

E – exercises (general exercise, specific exercises & training)

R – recharge (we need to have enough energy to engage with the programme, with others, at work etc)

M – movement is congruent with health, but you need to develop confidence to move

For more information Pain Coach | Specialist Pain Physio Clinics London | Richmond Stace