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The third leg of the stool

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Effective management of chronic pain, and every other chronic health problem, has 3 parts, and like a 3-legged stool, you need all 3 parts to optimally control a chronic condition. The first leg is things that are done to you, like injections, surgery, and chiropractic. The second leg is things that you do with a provider, like medications and physical therapy. Most people are pretty familiar with the first two parts. But we all know that the stool falls over if you don’t have all 3 legs. The third leg in managing chronic problems is what you do.

In other blog posts here, we have talked about a number of things that you can do, on your own, or with help from a health care provider, to help manage your pain. Things like exercising, pacing activity, avoiding or minimizing alcohol, and quitting smoking. Another crucial part of this is learning coping and management skills that you can use any time any day to help manage your pain.

We can change the way our brains perceive pain, and how we cope with pain. This is NOT to say or imply that pain is “all in your head.” Although, technically, no sensation, including pain, is perceived until the nerve signals get to the brain, and the brain assigns meaning to the nerve signals. So in a sense, pain is all in our heads, but so is all sensation, including touch, hot/cold, pressure, vision, hearing, etc. All pain is real, just like all other sensations are real. The sensation of pain is a complicated one, resulting from the brain’s interpretation of lots of different kinds of nerve signals. We can learn to modulate those signals and the interpretation, and change the way we experience pain.

We can group the skills needed to help manage pain into 5 basic categories: Understanding, Accepting, Calming, Balancing, and Coping. This is where psychologists and mental health counselors/therapists come in handy, because a good mental health provider is able to teach these skills to their clients. You can learn them on your own – there are a lot of resources out there – but it’s nice to have a guide on your journey when you first start out. There is a great article by Ted Jones, PhD, published in Practical Pain Management in 2014 that outlines these basic skills. Here is a simplified version of his article:

Understanding: Often people with chronic pain have misunderstandings about their pain. For example, people are hardwired to believe that “hurt equals harm.” When we do something that causes increased pain, we worry that we have caused harm. This misunderstanding leads to a condition that physical therapists call “kinesiophobia” and psychologists call “fear avoidance.” The rest of us say “I won’t do that activity because I’m afraid it will harm me.” In turn, that misunderstanding leads to a cycle of dysfunction and immobilization – in other words, the less you do, the less you are able to do, and the more pain you have when you try to do. Understanding breaks the cycle and leads to gradual improvement in function and pain.

Accepting: This does not mean giving up. This means accepting current limits, identifying what is still left, and working on realistic ways to move forward. When a chronic pain patient says “I just need to get rid of this pain!” – that’s not acceptance, and it’s generally not a realistic goal. Equally unhelpful and unrealistic is “should” thinking – “I should be able to do more,” “I shouldn’t have this much pain.” A wise person once said “Don’t should on yourself!” It sets you up for failure. Questions that can be useful to think about are “what level of pain can I manage? What kinds of things can I do with the pain and energy level I currently have? How can I slowly and gradually increase what I am able to do?”

Calming: Our brains and bodies get pretty agitated by pain, which triggers the “fight or flight” response. Our bodies’ reaction to stress makes this even worse, which then makes pain worse. Learning physical and psychological relaxation techniques, and techniques to reduce the body’s response to emotional stress, is a tremendously useful tool, and with practice you can get really good at it. There are lots of ways to do this, from simple diaphragmatic breathing to yoga, Tai Chi, meditation, visualization, biofeedback, etc.

Balancing: This means developing a lifestyle that is sustainable for you. It involves a number of smaller skills, such as pacing activity, developing good sleep habits, setting limits with friends and family, prioritizing activity, time management, assertiveness, and goal setting.

Coping: The nature of chronic pain is that there are good days and bad days. The goal of pain management is to increase the number of good days (when the pain is less bad), and reduce the frequency and severity of bad days. You’ll still have bad days, though. Coping is about developing a toolbox of techniques to use when the pain is more severe than usual, such as massage techniques, distraction, ice/heat, topical medications, and others.

This is not easy stuff to learn by yourself. Changing the way you think about your pain can be slow going and frustrating, at times. Depression and anxiety make pain worse, and complicate the process of learning and using these skills, even if depression or anxiety is caused by chronic pain, so that needs to be treated, as well. It helps to have a therapist who is skilled at teaching and helping you adapt these concepts to your particular situation, and to provide encouragement when you have a setback. It is worth it, though, and gives you tools that you can use to manage your pain.

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At North Shore Pain Management we provide advanced, evidence based, multidisciplinary and cost effective pain management. Our goal is to improve your ability to return to the activities you have been missing as well as provide a meaningful reduction in pain.

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