Level 2 Pain Training
Self Management and Chronic Pain
7th January 2016
Fife Integrated Pain Management Service
Ros Standish, Occupational Therapist
&
Dr Alice Wells, Clinical Psychologist
Schedule
 What is self-management?
 Over-activity rest cycle and pacing
 Exercise, Relaxation and Sleep
 15 mins Break (2.45pm)
 Barriers to self Management
 Behaviour Change
 Case Discussions and questions
 FIPMS
 Questionnaires and Feedback (4pm)
Wagner’s chronic care model
Wagner E H Chronic Disease Management : What will it take to improve care for Chronic
Illness?: Effective Clinical Practice 1998 1:2-4
What is Self Management?
http://www.paintoolkit.org/tools
http://www.paintoolkit.org/tools
Group discussion
•What previous experience do you have of
introducing/using self management with patients?
•What health conditions would self management
be important for?
•What does self management involve for the
patient?
•What does it require from the health
professional?
What is self-management?
Life with a long term condition: the person’s perspective
Interactions with the service: planned or unplanned
Problem solving: Time
limited consultation/s
providing motivational
support
Care planning: A system of regular scheduled
appointments, providing proactive structured
support
Care pathways: providing
specific interventions
NB : People may also be accessing a wide variety of other support e.g. from within their communities
Taken from the Health Foundation, Inspiring Improvement: Improving Outcomes by Helping People Take Control.
Self-management
 All patients with chronic illness make decisions and engage
in behaviours that affect their health
 People are experts in their experience of their own condition
 Health outcomes depend to a significant degree on the day
to day decision and activities that people with chronic
conditions make and undertake to manage their condition
Biopsychosocial Model
 Psycho & social part relates to the person as a
human being e.g. can you look the knee and
ignore the person…
 Social, cultural, personal dimensions interact
with pain mechanisms
 Understanding that each individual experiences
pain differently and it is actually hard how to
determine how any individual will react
Self-management: The Evidence
“is likely to work best when implemented as part of wider
initiatives to improve care through educating
practitioners, applying best evidence, and using
technology, decision aids and community partnerships
effectively.” (The Health Foundation, 2011)
Self-management: Why is it
important?
 80% to 90% of all care for people with LTC is undertaken by
patients themselves and their families.
 Patients with chronic pain often find medicine and surgery does
little to help their condition
Self-management: Why is it
important in chronic pain?
 Reported benefits of self management include:
 Fewer pain flare-ups
 Increased sense of control
 Less stress and improved mood
 Improved relationships
 Return to previously enjoyed activities
Self-management in Chronic Pain
Can include:
- Information on their condition
- Introducing self-management
- Psycho-education on stress and pain management
- Cognitive Behavioural Therapy and Acceptance &
Commitment Therapy
- Exercise and Relaxation
- Preparation for Flare-ups – Have a plan!
- Creating communication with the client to get an
understanding of their pain management expectations and
barriers.
Acceptance
Understand
your
condition
Flare
ups
Pacing /
Activity
Management
Sleep
The Pain Self
Management Jigsaw
Medications
Exercise
Pain Self Management
Jigsaw
Goal setting
Unhelpful
thinking
Relaxation
The overactivity-rest cycle
http://www.paintoolkit.org/tools
The overactivity-rest cycle
 In the long term
Good
day
Bad
day
Usual
activity
levels
Introducing Pacing and Activity
Management
• Recognising the over-activity rest cycle
• Awareness of habits – “I’ve just always done it that
•
•
•
•
way”
Tendency to push to complete perhaps because finds
it unsatisfactory to not finish
Encouragement to listen to signs of needing to stop
“Could you do the same again tomorrow?” –
promoting consistency and sustainability
Is it worth it? Values driven activity
5 Pacing Principles
 Finding your baselines – what time can I spend on an
activity before any increase in pain.
 Planning – plan activities through out the day and
including relaxation and rest breaks.
 Prioritising – what has to be done vs. what can wait
 Involving others – delegate if able
 Incorporating gentle graded exercise
Over Activity Rest Cycle V Pacing
Pacing/graded functional activity
Movement/Function
can occur
without increase
in pain
Movement/Function
in a comfortable range
Brain thinks
“ Situation
Better,
threat less”
Wind down, pain less
No longer
need red alert
Key messages on activity management
•
•
•
•
Everyone has choices about the activities they wish to pursue.
Pacing is a way to manage chronic pain on a daily basis and requires some
acceptance of their limitations.
Activities important to them can also be accommodated even if this leads
to flare-ups.
Its about managing activity in a way that works for the individual and
helps to maintain their quality of life.
Some specific strategies
Exercise
 Encourage regular gentle exercise (e.g. swimming, walking)
 Make it a part of everyday activities – reminding the need to
pace and plan all daily activities
 Many don’t think they can do it based on:
 Past experience
 Fears and beliefs
 Motivation
Education, benefits and de-conditioning
Active Options 2
Small manageable goals
Downwards spiral
Pain increases
Avoid
activities
Do less
Lose fitness
Pain on less
effort
Lose more
fitness
Do less
Pain on minimal
effort
Upward Spiral
Return to
other activities
Reduce fear
Try something
different
Increase confidence
Feel stronger
Try something
you enjoy
Feel in control by not
flaring up
Pain on minimal effort
Sleep
 Vicious cycle
 Sleep hygiene
 Time to unwind
 Regular bedtime- 8 hours before your alarm will ring the next day
 Avoid stimulants
 Lights out as soon as you are in bed
 If you do not fall asleep within about ½ hour, get out of bed and relax
in another room until you feel tired again.
 Repeat this step as often as you need to.
Some specific strategies
Relaxation
 Pain is influenced by emotional and social factors e.g. stress.
 Relaxation exercises calm your mind, reduce stress hormones in your blood,
relax your muscles, and elevate your sense of well-being.
 Relaxation isn’t just watching TV…
 Diaphragmatic breathing
 Progressive muscular relaxation
 Guided imagery or visualisation
 Mindfulness
Visit www.moodcafe.co.uk or http://stepsforstress.org/ for relaxation
exercises and CD
15 minute break
What are barriers
to Self
Management?
Group discussion (10 mins)
•What barriers have you encountered?
•What barriers might you expect to encounter?
Barriers to self-management
• Hurt and harm beliefs
Ask:
– What do they think is happening inside their body?
– Why do they think they experience symptoms?
• Pain education - weaken the grip of pain with
knowledge and understanding to allow patient to
rationalise and reason their symptoms
• Gently challenge their beliefs e.g. Is that knee older
than the other? Does the spine not crumble on a good
day – would an XR/MRI look different on a bad day
than the day before?
Barriers to self-management
 Depression
 Persistent low mood and hopelessness
 Patient may not see the point in self-management
 Poor motivation and enjoyment
 Patient may be unable to motivate themselves to change
their behaviour and sustain any changes
 Disrupted self-care
 Affected concentration and memory
 Patient may be unable to take in and/or remember selfmanagement advice
Barriers to self management
 Unhelpful thinking styles
 Black & white thinking
 Catastrophising - Assumption that the worst is
happening and will continue to happen
 Rumination -strongest predictor of poor prognosis
 Education
 Challenge assumptions
 Graded exposure
 Groups
Barriers to self-management
 Locus of Control
 “the extent to which
individuals believe that they can
control events that affect them”
 Internal vs external
 An external locus of control would influence an
individual’s adoption of self-management
Barriers to self-management
 Fear avoidance
Ask:
 What do they think would happen if....? And what would that
mean?
 Observation- do they use their hands to lean on things?
 Pain education
 Graded exposure approach to exercise
 Groups
Downwards spiral & mood
Pain increases
Avoid
activities
Do less
Lose fitness
Pain on less
effort
Lose more
fitness
Do less
Pain on minimal
effort
Barriers to Self Management
 Expectation of Roles
 Roles of the patient
 Role of the carer
 Role of the Health Professionals
 Role of Others
Barriers to self-management
 Resources vs demands
Self-efficacy and health behaviour
change
 Transtheoretical or
“Stages of Change” model
Increasing motivation and exploring
ambivalence
 Communication is key:
 Understand the patient by listening
1. ‘Why do you think you have chronic pain?’
2. ‘What does your pain mean to you from your point of
view?
3. ‘How has the pain impacted on your life from your
point of view?’
4. ‘What would be important things for you to work on?’
5. ‘What do you think would help?’
Increasing motivation and exploring
ambivalence
 Education
 Validation/understanding patient
 Evoking change talk (motivational interviewing)
 Encourage
 Small steps
Increasing motivation and exploring
ambivalence
 What would you like to see different about your current
situation?
 What makes you think you need to change?
 What will happen if you don’t change?
 How can I help you get past some of the difficulties you
are experiencing?
 If you were to decide to change, what would you have to
do to make this happen?
INFORMATION
 Book Prescription Scheme
 Maintenance Exercise Classes and Active Options 2
 Web Sites:
 http://www.knowledge.scot.nhs.uk/pain/nhs-
boards/nhs-fife.aspx
 www.chronicpainscotland.org
 www.painassociation.com
 www.painconcern.org.uk (Airing Pain Project )
 www.paintoolkit.org
 www.moodcafe.co.uk
Acceptance
Understand
your
condition
Flare
ups
Pacing /
Activity
Management
Sleep
The Pain Self
Management Jigsaw
Medications
Exercise
Pain Self Management
Jigsaw
Goal setting
Unhelpful
Thinking
Relaxation
STRUCTURE OF SERVICES
HOW AND WHEN TO REFER
 Who are we and where do we fit in?
 How do I access the Chronic Pain Management
Service?
 Who should I refer?
 Who should I not refer
 What should I do for my patients before referral?
Kaiser Permanente Model
Secondary Care
Complex patients
Primary Care RIVERS Program
Less complex patients
Mostly musculoskeletal pain
Chronic Pain Patients
Cared for in General Practice /
Self-Care/ CPPN
HOW DO I REFER?
 Referrals should be sent to:
 Pain Clinic (FIPMS), QMH
 Patients are triaged centrally to most
appropriate branch of service.
 Triage is influenced by referral letter, HADS
score ,PSEQ coping skills indicator and
patient information from questionnaire.
Fife’s Pain Service
Patient requiring Pain Management -Referred by GP/
Physio/ Other
Jan 2012
Central Point of referral
Pain Clinic QMH
Questionnaire sent to
patient to be returned
within 2 weeks
Questionnaire/ Referral letter
triaged to intervention depending
on complexity
Less complex: Primary Care
More complex: Secondary
Patients attend
information session x 2
CONSULTANT
Physio Pre-assessment
NEW
Community
Pharmacy
Med review
clinics
Pharmacy Appt
One to one appts
Joint Assessment
NURSE- PHYSIO –
OT- Psychology
RIVERS
5 weeks ( Exercise & Education &
Medication Review)- Group of 10- 12
pts 4/5 venues across FIFE
‘Keeping Afloat’ exercise class
Kingdom Pain Management
Programme
10-12 weeks :2 venues
across Fife
Voluntary Sector Maintenance- Pain
Association Scotland/ Pain Concern/