General Practitioners working with patients suffering chronic pain

GP
Sergio Santos

Are you a GP who sees people suffering chronic pain?

The answer is most likely yes considering 20% of the population suffer chronic pain. There are many presentations (in no particular order): back pain, neck pain, irritable bowel syndrome, fibromyalgia, arthritis, post-injury, headaches, migraines, pelvic pain, endometriosis, menstrual pain, tendonitis, as a feature of a particular condition, cancer, heart disease and more.

Chronic pain is the No1 global health burden. Pain is the main reason why people seek help. Yet it remains poorly understood, meaning that people’s expectations are out of step with what they need to get better, and the treatment offered can take them down the wrong path. Together these contribute to the on-going problem that is showing no signs of change in the right direction: less suffering and less cost. We must and can make this happen. The ‘we’ being society.

GPs are in a prime position to help drive this change with the right support and systems in place. As a GP or healthcare clinician, how do you feel when a patient (person) suffering chronic pain comes into your room? Be honest. Does the challenge excite you, or is it the so-called ‘heart-sink’ time? For me, I have always loved the challenge and the fact that we can always do something to help the person improve their life. But this is because I have always felt that I can work in this specialist field and make a difference, building knowledge and experience over 20 years. Without the practical knowledge and the coaching approach, I am certain I would feel lost and overwhelmed.

Now, I do not believe that you need 20 years in the world of pain to be able to have a positive impact. But I do know that understanding pain is vital, as is having confidence in your approach. Both are transmitted to the person in front of you whether you are aware or not.

Steps to take

The first step is to be aware of your own beliefs, biases and behaviours in these situations. These will frame your approach. What is your approach? Establishing the way you ‘treat’ is the next step. Do you treat chronic pain? Do you treat the person? Do you coach the person? What do you do, how and why?

On knowing your start point, you can then build your knowledge of pain: what is pain really? For example, understanding that pain and injury are poorly related, that pain and tissue state bear little relation to each other, that pain is a need state, and that pain is the brain’s best guess to explain the current state. Further, you learn that pain is related to the perception of threat and the state of the person. It is of course the person who suffers pain, not the body part. And, most of the biology in the dark when we are in pain, is not actually where we feel it. The pain experience itself is just the tip of the iceberg.

Your process

You have a choice. You can continue using the same approach, and indeed there may well be some ways that you find to be effective. Or you can add to your repertoire of tools and design a system or process. This I can help you create.

One of the biggest challenges is always the time factor. Perhaps you have 7 minutes, 10 minutes or the ‘luxury’ or more. It is tight. This is a complex situation that requires time and the human touch. How can effective care be achieved? How can we really help this person improve their life? The primary choice remains medication. There is a role for medication and it is often expected by the person and hence a pressure to prescribe exists. However, whether you do or not is your choice as the clinician. But of course medication does not teach someone how to improve their life and will mean that the natural systems of (biological) protection become lazy together with a limitation upon the person’s responses. People commonly rely upon and hope for the quick fix option when there is none. Instead there is a way forward that eases suffering and improves life, but it takes longer and is more effort. That is the reality, the uncomfortable and inconvenient truth about chronic pain.

To address pain you have to address your needs in life, build wellness, create new heathy habits, take a new perspective, expect and know that life can get better and practice day to day to day, much like cleaning your teeth — you know this is true when you truly understand pain.

The questions are: what does this person really need? What are they telling you in the narrative? And then, how good are my deep listening skills?

So, with limited time and the desire to make a positive impact, we need a plan. One that we can roll out in an individual way. We need a set of options and resources that can meet the needs of the person step by step. When you know that you have a plan, the pressure eases because you know that you can make a positive impact. You outline the plan to the patient, start the wheels turning as you help them understand their pain (always the key), and focus on what they CAN do to improve their life.

Pain Coach
#upandrun project >> ultrarunning + UP workshops to help people understand pain and move on to a fulfilling life

The Pain Coach approach focuses upon what the person wants in their life and how they want their life to be: focus on what you want, not what you don’t want. See how often we do the latter, and sure enough…. . This is why coaching offers so much because we tap into the person’s strengths to move on towards their picture of success. We have a clear direction and steps to take each day. It is a challenge, but coaching encourages and supports the person to live their best life, to show up in the best version of themselves, and to reach their potential.

What would it be like if you had a process?

How would you feel about supporting, encouraging and coaching people suffering chronic pain if you knew that you had a process in place? Would this have a positive impact upon their lives? Your practice? Your stress levels? Costs?

Your process includes a range of ways that you address particular problems that arise together with resources to call upon. Within each session you have 1-2 key points to cover. Sessions are scheduled according to the priorities for that person. This removes some of the time pressure because instead of trying to cram in as much as possible, or prescribing as the first port of call, you know that you have a number of appointments set up for particular issues to be discussed and acted upon.

In essence, when a person has an idea about what is happening, why, what they must do, what the clinician will do and over a rough time period, they will be satisfied and engage. The trusted advisor status is vital when working with someone suffering chronic pain. This takes time and follows reliable, compassionate care, i.e./ positive actions in line with the person’s needs.

Summing up

There are many pressures upon GPs. From society, patients, and themselves to deliver the best care. Resources are always limited in some shape or form, in particular the most valuable one: time. This being the case, we must work out the best ways of moving forward. For chronic pain, currently the greatest health burden, creating a process within your practice that enables you to listen (deeply) to the patient, and step by step meet their needs will increase efficiency and improve outcomes. Within this process, pain coaching is a means of working with the person so that they can reach their potential.

RS

Richmond Stace is a Specialist Pain Physiotherapist, pioneer of The Pain Coach approach for chronic pain, co-founder of Understand Pain social enterprise and an Honorary Clinical Lecturer in pain at Queen Marys University London.

For more information about Pain Coach Mentoring for you or your practice and Understand Pain Workshops for people suffering pain, contact us here >> richmond@specialistpainphysio.com

#upandrun ambassadors

26th June 2019 NEWS

UP has two ambassadors joining #upandrun

As the UP story gathers momentum, in particular the #upandrun project (ultrarunning, marathon running and the UP education programme), we are delighted to welcome two new UP ambassadors: Chris and Jeff. Both will be running for #upandrun so keep an eye out for blogs, pictures and always the hashtag!

If you see #upandrun hashtag, give us a shout out! Take a pic and post it on Twitter or Instagram.

Chronic pain affects so many people for so many reasons. The measure of our success will be how many people we can inspire to move on to live their best lives.

This week look out for…

Richmond running along the Thames Path tomorrow (Thursday) from Hampton Court to the Thames Barrier

Next week look out for…

The UP talk and workshop on Weds 3rd July at 2pm at The Groves Medical Centre. Get your place here >> tickets

On we go!

London to Brighton May 25th ~ a few tips on keeping going

London to Brighton 100k 25th May

The next stage of #upandrun for Understand Pain is the London (Richmond upon Thames) to Brighton. 100k from city to coast. I lived in Brighton for some years, so it feels a little like running home.

This time I will be doing it in one day; the full 100k. Of course I am expecting and preparing for challenging moments along the way. That’s why we do it! To face, overcome and complete.

Running can be a great metaphor for life. Inevitably life is full of ups and downs. These are unavoidable. However, our approach and attitude define them as opportunities or obstacles. Whilst these moments maybe hard and unpleasant, the way we view them determines whether we learn and move on or suffer more than is necessary.

The tougher moments when running include fatigue and heaviness in the legs, knowing that despite going for hours, there are still hours remaining, and various aches and pains. I’ll share a few strategies that I use to re-focus and keep going.

1. Re-focus on what you want and keep going

Everything comes through the mind. The mind is embodied. These are both important considerations. There is no separation between body and mind. Instead we have a (whole) person. The way we think is embodied, the decisions we make are affected by our body state, and our bodies keep the score of all our thoughts and emotions. Skilfully appreciating this and using it to our advantage is one of the habits of peak performers. We can all be peak performers in our own way.

In that tougher moment, you learn to take a perspective and re-focus on what you want to achieve as an outcome. What is my picture of success, or dream? When you focus on what you want, you feel your energy lift. In one way, this is how you know you are focusing on your picture of success rather than something else. For instance, paying attention to the feeling of heavy legs and any on-going thoughts brings on further sensations of heaviness — it gets worse.

2. Remember your purpose

Knowing one’s purpose is healthy according to research to date. Since Viktor Frankl wrote Man’s Search for Meaning, there has been interest in purpose as something that spurs us on, gets us up in the morning and drives persistence in the face of adversity.

Many people run with purpose. Often this is for a cause such as a charity, chosen in the name of a loved one who suffers or has passed on. I believe that is why events such as the London Marathon are so emotive.

In that moment when it is ‘sticky’, you recall your purpose, the person or people you are representing and drive on. You know that no matter how much it hurts right now, it is nothing compared to the suffering of others.

3. Fuelling skilfully

On longer runs, your fuelling is essential. It is also personal and unique in as much as each person must find out what they need. The experimentation should take place on training runs so that you know and can prepare fully for the actual event.

The night before I always have a (big) bowl of spaghetti bolognese. In the morning, I am up early having porridge with blueberries and honey. At least one shot of coffee is also essential for me, together with two shots of beetroot juice. Until the start, I will nibble: a banana, a Pursu nutrition bar, cashew nuts; and sips of water.

During ultra runs, I re-fuel around the first 10-12k mark and then at the rest points. On the Ultra Challenges, the rest points are every 10-15k ish, offering a range of fruit, pastries, cookies, flapjacks, sweets, coffee, water, sports drinks, pick n mix, hot meals (at lunch) and more. Typically I will have a banana, salt and vinegar crisps, a cookie, water, a shot of coffee, pick n mix (yum!), watery fruit (e.g./ melon), sports drink and refill my bottles. I carry gels and use them as needed, but typically towards the end when I need a little booster.

The principle I follow is to keep hydrated and fuelled rather than wait. I used thirst as a guide, but only very mild thirst, sipping regularly, especially if it is hot. When I notice a particular type of heaviness and I know that there is a way to go before the next stop, I will use a gel.

Marathons are different because the are no rest points; the run is non-stop. Fuelling and drinking are on the go. It can be messy!

Whichever way you find works, it is a key strategy to use in order to keep going.

#upandrun moves on to the Isle of Wight

It’s been a great weekend in Brighton, but now it’s straight back into training to be ready for the Isle of Wight Challenge at the start of May. That means a 20k trot today.

The route yesterday was lined with supporters giving enthusiastic encouragement. Some of the stretches were long and straight, meaning that as you were running, you could see the sea of bobbing heads stretched out in front for some distance. Coming back from the power station to Madeira Drive, the 360 and the pier were landmarks. With the wind blowing at you, they seemed so far away!

The final stretch to the finish line is an incredible moment. The crowd are going absolutely crazy and because you are stretched out, it feels like you are the only runner. Suddenly you’re filled with energy and find yourself sprinting (it feels like sprinting…) to the line. Awesome!

So now onto a longer run that is a totally different experience. My preference is off road, trailing running so although this is 53k x 2 (Sat/Sun), for me there’s no sense of needing to hit a pace. Instead it is about enjoying the ride, meeting others who are in for the long haul and marvelling at the scenery of the island’s coastal path.

As ever, this is for UP, so do follow us with the #upandrun as we seek to raise the awareness of the problem of pain, especially chronic pain, and what we can do as a society to ease suffering.

RS

#upandrun Pain Points (6): there is no quick fix for persistent pain but you can understand your pain and move on to a fulfilling life

Me with Sanjay who created Pursu nutrition bars

There is no quick fix for persistent (chronic) pain, but you can understand your pain and move on to a fulfilling life

In a world where we have become accustomed to immediate gratification, the really important things take time and effort. For example, relationships, work satisfaction and wellness. There’s no quick fix for any of these, and the same goes for pain. All require understanding, a picture of success that you work towards each day by taking positive steps. This is normal.

People often ask if they can get better. I say yes. We can always improve and get better. What does this mean? It’s individual of course, but in essence it means that the person feels liberated from their suffering and is able to live a fulfilling life. Do they still experience pain? Probably. But there’s a big difference.


A suffering society ~ time for change

Pain is part of the way we protect ourselves and survive. It is normal and necessary. Yet why do so many people continue to experience pain when there is no immediate threat or danger? Similarly, why do people who suffer PTSD continue to suffer repeated episodes? Why do people with anxiety disorders feel anxious when nothing is actually happening? Why do people feel depressed when there is joy all around? Hopefully you can see the similarity in the patterns here. The words are interchangeable and the suffering immense. This can and must change, and driving this change is the purpose of Understand Pain.

The answers to these questions lie in the way we live and the way society has evolved and is working. This is why a social shift is necessary as we develop a new level of consciousness, understanding the causes of suffering so that we can focus on building wellness.


The difference is the impact factor. The inner disturbance lessens, life fills with meaning and great states more often as the person pursues a purpose and reconnects with people and the planet. We only have a limited capacity for awareness, so when we fill this with people who inspire us, support and love us, when we share and give, when we get outside into nature and feel that we are contributing to something greater than ourselves, life transforms.

There is no super-highway. To achieve a better life requires us to know what that life would look like and take steps in that direction each day. We need a clear direction and tools and practices to use to keep us motivated, orientated and an awareness of the achievements along the way.

We are designed to change — life would not be possible without change. Embracing this natural development, we can learn to create the conditions for moving on, whatever our start point. We continually ask questions of ourselves and the answers determine the quality of our lives via the answers and what we focus upon and decide to do. So asking the right questions is key. Here are some examples >> What CAN I do? How can I build my energy? How can I best look after myself? What steps can I take today towards my picture of success? What can we do together to move forwards? What is the best decision now? And now? Whatever you ask, you will answer.

Suffering chronic pain, you are likely to need support, help and encouragement with practical advice about what you must do each day. Pills do not provide this, nor any other form of quick fix. We are encouraged to push down emotions, distract and turn away yet it is by facing our ‘stuff’ and all the reasons in our life why we continue to suffer. This takes courage but it is the way to transform our lives. And we all want the best life we can create.

Sanjay is a superb example of someone who did exactly this, moving on to a meaningful, fulfilling, challenging, scary, exciting project, Pursu. I would encourage you to read his story on the Pursu website as he has created both an incredible product but more so is the meaning behind it and what he is doing to contribute to society. And this from a story of pain: Sanjay’s story

On May 22nd I will be talking about this and more, giving practical tips and knowledge about pain to help people gain insight and move on. This is free and you can get tickets here

Together we move on.

RS

#upandrun >> the day before the Brighton Marathon

The day before the Brighton Marathon

Look out for the orange shirt and share pics >> #upandrun

I am pretty excited now. As usual I woke early, so we will get on the road to the South Coast. I’ve not done a road marathon since the London in 2017, and that brings back great memories.

This week has been a coaster, or tapering, which has its own challenges that are more mental than physical. Although it all comes as one experience of course — I don’t want to disappoint regular readers into thinking I have become a dualist!

I have noticed that the really short, easy paced runs of between 3 and 8 km to be more tough than the long ones! Although important to keep moving and the feel of the stride, I find them heavy, rather boring and puffy (I puff). There you go.

Anyway, it’s off to Brighton, one of my favourite places, to pick up the running pack, take in the sea air, meander through the lanes, end up with a big bowl of pasta and an early night.

If you are supporting or coming to watch the Brighton Marathon, give me a shout and a wave, take a pic and share with #upandrun so we can spread the word and gain momentum. Understand Pain is all about a better world that we can create together.

RS

#upandrun Pain Points (5): Pain can and does change

Pain can and does change

This is a strong message and one that must be realised.

Life is only possible because of change and impermanence. Each moment unfolding is new, and fresh. Bodily sensations such as pain appear in our awareness as the objects and contents of consciousness, just as thoughts, sounds and what we see appear to us. This is our lived experience. When we stop and watch our own experience, this can be realised.

What often stays the same and recurs is what we tell ourselves about the pain we are feeling. Of course this can be reinforced by the fact that the same things are challenging each day. We attach to our stories. The inner dialogue can be so influential despite the fact that much of what we tell ourselves is untrue, self-critical or pure nonsense at times. What we need is a self-encourager that comes from self-compassion.

A problem that we can all have is the remnants of, or continuation of coping strategies that we once learned to shut off from stress, avoid pain and protect ourselves in the short term. However, in the longer term, the coping strategies cause dysfunction and prevent us from getting better and improving our lives. These are not set in stone and we can create new habits that build wellness and resilience, which support us create a better life.

Mindful practice and meditation is one way of realising this experience, gaining insight into the difference between the sensations of pain and the thoughts that we have about the pain. Learning how to observe our thoughts, feelings and experiences enables us to cut through the sense of self, be in touch with reality (the present and only moment), let go and liberate ourselves from on-going suffering.

Buddhism talks about the two arrows. The first arrow is the pain that you feel. The second arrow is the suffering caused by the way you are thinking about your pain. Learning about the knowing the difference is important.

There is much to be hopeful for. For some years I have focused on helping people gain insight into their suffering and what they can do to move onward. Compared to 10 years ago, people are much more open to what we know about pain rather than being dominated by limited beliefs and social conditioning that we are all subject to in unique ways from childhood through. The research and study of pain continues to reveal much that we can distill into practical tools for day to day use. Improving lives is a learning process, taking on new habits to build momentum. Some of the skills initially surprise people, but soon enough they realise their potency in changing our experiences sustainably.

RS

#upandrun Pain Points (4) Pain is a need state

Somewhere I was running

Pain is a need state

Pain can be thought of as a need state like hunger or thirst. Similarly, emotions are considered to be indicative of our inner physiology that guide as towards a range of actions to make sure that we maintain healthy parameters.

Pain is an experience unique to the person. It cannot be seen, it has no shape, colour or form. Pain is typically hard to describe although we have a large number of words that attempt to capture the feeling. Using the word itself tells us that the person is having or has had an experience of the sensation, yet it tells us nothing of the type of sensation. The particular qualities are always private and part of the inner world. Much like thirst. Try and describe the sensation of thirst…

What is a need state? This is when we become aware of a feeling, often closely associated with thoughts (the brain basis of thoughts and feelings co-exist, which makes sense), which has the purpose to motivate action. Our brains and its body systems need each other, and this is part of how we obtain what we need to survive. Our brains are only interested in survival, which is why many people suffer as a consequence of the lives we lead within the current society.

We are designed to look out for danger, and together with the ability to think back and ahead, we can perceive threat very easily. As we keep practicing this, we get very good at it! The consequences of worrying about things that usually don’t happen, or replaying past unpleasant events include all sorts of common ills. For example, chronic pain, IBS, headache, migraine, functional movement disorders, anxiety, depression, pelvic pain, skin disorders and autoimmune diseases. The reason is because we become ‘inflamed’ by the way we live, spend much time in a protect state and hence the healthy mode is quashed. We can change this as soon as we decide to improve our lives in a number of ways.

All of these feelings mentioned above are all signs. They create the opportunity to make changes, create new habits and build a better life. This makes sense because there are many ways we can now satisfy our wants, and indeed society encourages this everyday. You may want to buy things, accumulate stuff, eat junk food, drink alcohol, smoke cigarettes and more. Yet we do not need these things, which only bring very short term relief before the next urge.

Pain as a need state to be transformed requires facing the reasons why the person remains in pain. This can be challenging because we don’t usually like to deal with our ‘stuff’. Instead, it appears easier to take a pill or have an injection or something else that appears to be quick fix. However, none of these things truly transform suffering and liberate the individual. Medical care can contribute a little, but it is the work of the individual to understand their true needs and meet them each day that makes the difference. Pills do not teach you how to live well moment to moment. You must learn the skills of being well in your own way.

This is the purpose of The Pain Coach Programme. To deliver the insight to people so that they can understand their pain and move on to a fulfilling life. This is whether they are a struggling athlete who feels on-going pain, someone with a condition that features pain, a person who feels life has got on top of them and they hurt (and feel exhausted all the time), right across the ages and certainly spanning our society.

We must revise our thinking in society so that the suffering eases. That’s the purpose of Understand Pain (UP and why I am running (follow #upandrun on Twitter) many miles, writing these blogs and giving talks. We can do this together, so please share! All of what I write is based on the latest research and understanding of pain, so whilst it may sound different (and I hope it does), this is because we have been conditioned to believe something more simple. But the more simple version is not solving the problem. It is likely making out worse because people are continuing to rely on drugs and other means to get better, when they do not provide the answers. You do.

RS

#upandrun Pain Points (3) ‘Pain is whole person’

One of the final tapering runs, in the sun #upandrun

Pain is whole person

What does this mean? Put simply, pain is experienced by the person and not by the bodily location or part. In the case of back pain for example, it is not the back that is in pain. Instead it is the person who experiences back pain. This is no different to thirst in as much as the mouth does not experience thirst and head off to get a drink. The person does.

Now, what does ‘whole’ refer to? Again this is a key point of understanding. There are no separations. We are whole. The lived experience, what it is like to be ‘you’ in any given moment, emerges from the meeting of thoughts, perceptions and actions (enactivism).

One of the reasons why considering the whole person is so important is because it is the person that we treat. Pain is poorly related to tissue state, but it is well related to the state of the person. It was Oliver Sacks, the famous neurologist and writer, who stated that it is as much about the person as the condition. He was a man of great compassion and insight.

Conditions in name are lists of signs and symptoms. They are brought to life by the whole person in a unique way with all his or her thoughts, feelings, emotions, expectations, hopes, priors and beliefs, each in a different environment and context. A huge number of variables exist within every unfolding moment. Listening to the narrative illustrates this, which is why deep listening is important.

The model that best represents the whole is the biopsychosocial (BPS) model. Truly using this approach means that the biology, psychology and sociology of pain are considered, in relation to each other. It is in the middle of these overlapping dimensions that the person’s experience sits. This is what we seek to improve, the lived experience.

When we focus on the person and what they want to achieve in their life, we can design a programme that encourages and supports them to take steps in that direction each day. This can only be achieved by thinking about the whole person.

RS

#upandrun Pain Points (2): pain and injury are not the same

CRPS UK running vest for the Brighton Marathon

Pain and injury are not the same

There is a straightforward difference between pain and injury. Pain is subjective and injury is objective. Pain is a lived experienced. An injury is a disruption of the body tissues. You cannot see pain. Usually, you can see an injury.

Unfortunately the words are often used interchangeably. Further, there is the belief that pain and injury are well related. However, we have known that this is not the case for many years. Pat Wall, one of the forefathers of modern pain medicine and science, spoke about this in his famous 1979 lecture. Since then there have been countless studies showing that pain is part of how we protect ourselves and related to the state of the person within a particular context.

We have many stories of varied pain responses to different injuries. Sports people continuing to play with sprains and fractures, soldiers sustaining severe physical trauma reporting no pain, and the large proportion of people suffering the symptoms of IBS without any notable pathology. More-so, there are no investigations that show pain. Pain cannot be seen on an X-ray or an MRI scan.

We must be clear. People suffering pain must understand why they feel pain, why and how it can persist, and then focus on the steps that they can actively take to move on and get better. Misunderstanding pain is one of the main stumbling blocks. Erroneous thinking results in wrong decisions about treatment and self-care, but also impacts upon the sense of empowerment, belief in oneself to improve and hope.

Truly understanding pain helps the person to let go of unhelpful and fearful thoughts and to build confidence (in moving for example). It creates a strong foundation from where the person can build and gather momentum towards their picture of success.

RS