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Working With People In Pain

Connie Jasinskas M.Sc., Certified Exercise Physiologist, ATRI Faculty, Pain Educator

In the rehabilitation world, pain, and sometimes, chronic pain, are an unfortunate part of the patient condition. As therapists, trainers, and rehabilitative aquatic exercise specialists, strategies to help patients cope with or reduce pain are always important. Patient pain education can be a useful tool to increase understanding. In my experience, when people comprehend neuropathic pain, self-responsibility in the healing process is more easily achieved. Quality of life is improved.

This article will outline simple strategies to use during pool sessions with pain-affected patients. It will also describe a successful Patient Education Program (PEP) that is being used at a physiotherapy clinic in Cambridge, Canada.

Pool Strategies for Pain-Affected Patients

Unwinding
This is taught during initial pool sessions, and encouraged throughout treatment and beyond. The following strategies can create deep calm and are useful for down-regulating the autonomic nervous system before and during pool sessions. Patient trust in your process is built along the way.

Unwinding strategies include:

Thorough pool orientation to decrease stress and fear. This includes information offered to patients before they come to the pool, and during their first session.
Frequent gentle reminders to “breathe”, “let go” to encourage slow diaphragmatic breathing.
Floating (the whole body or affected body areas). For example ‘sit’ against a wall wearing a neck collar. Lower the body to the depth where the neck is supported. Allow the arms to float as they will, completely relaxed. When possible, the patient will be asked to try supine relaxation techniques in the warm pool. The patient will be appropriately supported with flotation equipment. Ear-plugs may be worn if desired. The therapist can then gently move the patient around the pool, encouraging him or her to imitate a piece of seaweed or cooked spaghetti. It is an excellent way to see and feel areas of tension in the body. It also promotes profound relaxation in many patients, and (no surprise to most of us), diminution or abolition of pain! Patients quickly learn to appreciate the affects of deep relaxation on their pain responses. We discuss how they can duplicate this relaxation at home, to extend their pain free, or pain reduced time.
Calming or joyful visualizations – one woman’s pain was dropped instantly by thinking of her grand children.
Use of humour – just smiling on purpose changes physiology and pain levels.
Oscillation – self or therapist initiated – gentle small movements of the limbs or core.
Watsu.
Self or therapist massage.
Soothing music, soft voices, noise reduction.
Soft lighting / eyes closed.
Restriction of aggravating thoughts or discussions.
Encourage being in the moment – leave the outside world behind.

A Holistic Approach
Often in the medical system, pain issues are treated as unique sites on the body. Time or consideration may not be given to how other parts of the body respond to the pain site. For example: A painful lower extremity will almost certainly affect the low back (shoulders? neck?...). The unaffected lower extremity will often have foot, ankle, and IT-‐Band tightness due to antalgic gait. It is useful for people to make the connection between postural abnormalities and headache occurrence; between mental stressors and pain levels. Discussing and understanding cause and effect, then addressing pain throughout the body is both useful and appreciated.

Patient / Client Self-Responsibility
Encourage patients to ‘take ownership’ – to be present and involved in their pool experience. Patients who are active participants in their sessions tend to experience much better results. Once learned, the following can be initiated by the patient both in and out of the pool:

Unwinding, diaphragmatic breathing, self-relaxation through thoughts and activities
Reframing their thought processes – leaving negative emotions behind, using humor, smiling – even if they don’t want to – it still works!
Intuitive movement – for stretches, oscillations, AquaStretch™…
‘Doing their homework’ regarding pool and home-based exercises, postural modifications, lifestyle modifications, and reduction of pain aggravators.

Other Strategies for People in Pain

Medications: Clients in pain will often be on medications for pain. Discuss this, and help them establish appropriate use of pain medications before and after pool sessions.

AquaStretch™ Facilitator Pressure: Use very light pressure to resolve adhesions, until or unless more pressure is desired and required. Some Clients are so sensitive to touch that no Facilitator pressure is tolerated. In this case, you may instruct the Client (where possible) to use their own hand or a Thera-cane (or similar device) to exert the pressure themselves. Adaptation of AquaStretch™ Procedures for people in pain can be addressed through further education in this specific topic.

Pool Attire: Be sure people are warm enough. Encourage people to wear additional clothing if pool water or air temperature are chilly. Women’s swimsuits that tie at the back of the neck can exert pressure on the neck and shoulder muscles, increasing muscle guarding, headache, and pain in these areas. Advise strapless, full shoulder straps, or if possible, re-tie neck straps so they come under the arms and tie mid-scapula region behind the back rather than behind the neck.

Take Breaks as Required: Check frequently as you move through pool sessions. Sometimes, pain management breaks can be encouraged as required, using deep breathing or pain resolving postures. Check often (observe / ask) regarding patient warmth and comfort. Anything that agitates the central nervous system (CNS) will likely increase their pain. A shorter, more comfortable session is likely to have them return and achieve better results in the long term. Remember that for pain-affected people, small amounts of ‘comfortable’ activity in the pool can result in hours or days of pain afterward. Start by doing less than what seems possible, and build from there, based on response. Neuroplasticity is involved in creating neuropathic pain. The body needs to slowly re-learn that activity is not the enemy.

Individualize Your Approach to Activity: Clients differ, as do pool characteristics (including warmth). Play with the order of: relaxation – AquaStretch™ / therapeutic techniques – gentle graded exercise. The goal is to find the best fit for each Client. Coaching of ‘ideal’ alignment and stabilization in the water is crucial, but some patients will need adaptations to decrease aggravation of pain. Depending on the site of pain, and therapist or MD recommendations, the following aquatic movements will be explored and used: gait training, suspended core stabilization, immersed extremity movements to gently mobilize hips and shoulders; spinal stretches that reduce muscle tension and pain. Explore movements, stretches, activities, and positions that improve or aggravate pain, and adapt as required to exercise comfortably in the pool.

Educate: Use ‘teachable moments’ to offer insight into how posture affects neck and shoulder pain; that all pain is real pain – it all comes from the brain; how small lifestyle modifications can help reduce pain; how neuropathic pain happens for some people and not others; that their pain is not their fault; that ‘too much – too soon’ is not what we are after with exercise, but ‘motion is lotion’ and they need to ‘move to improve’!

PEP – Patient Education Program for the Clinic

The PEP program was initiated to help patients and therapists alike. Classroom teaching time is allocated for small groups of patients to learn about pain mechanisms, and practical coping strategies. Improvement of quality of life is the key goal of the PEP classes. Sessions include the following:

Education about pain: the difference between acute, sub-acute, and chronic pain. We prefer to use the word ‘persistent’ pain.
Patient resources: books, apps, worksheets, DVDs, CDs, helpful websites about self-reflection, meditation, breathing, exercises.
Practical coping strategies are taught and practiced: the power of breathing, humor therapy, self-myofascial release techniques, the use of ice / heat as appropriate, ways to improve restful sleep, stretches and exercises that help.
Empowerment of the patient by teaching ways to reduce / eliminate factors that aggravate pain.

The program was initiated because, in our clinic, we found that therapists often lacked the time during patient visits to fully explain these concepts. The PEP classes allow us this time.

This program has a very limited number of contact hours – only three sessions, with a total of less than four hours. Ideally, sessions would be expanded to double or triple that amount of time, but cost is always a concern. The program highlights what is available in our practice and in our community (beyond the scope of PEP) that can assist our patients in dealing with their pain. In the time we have, patients learn about: the mechanisms of persistent pain; that their pain is ‘real’ but may exist with no ‘issue in the tissue’; that it is not their ‘fault’; and that they have the power to do something about it!

Our PEP classes were created to help especially those people who, for reasons not fully understood, head down the persistent pain pathway. Therefore, we want to see patients early in their treatment program. Ideally, they are informed about, and booked into their PEP sessions early in their treatment plan.

The shape of the program:

People attending the program are from all walks of life, ages, cultures, and educational backgrounds. Many have experienced workplace injuries or traffic accidents. Language is kept simple, with lots of opportunity for questions, explanations, or further depth of information, as required. People are made to feel comfortable, and encouraged to get out of their chair, move around, or lie down, if that is their most comfortable position. Our training room is quiet, private, and comfortable. We have no more than six patients per training session.

The program takes place over three sessions, usually held a week apart. The first session (1.5 hours) involves introductions and climate setting as a prelude to pain education. It is important to note that many people coming to the program are angry, frustrated and upset by their pain experience and their interaction with insurance, employers, the medical system, and family members involved in dealing with their situation. They are also IN PAIN! Therefore, climate setting is an important aspect of their introduction to this material. The instructor introduces herself, giving a brief overview of the session objectives, reinforcing personal comfort (in whatever shape that may take) during the session. When settled and comfortable, people are asked to briefly introduce themselves. They may share their pain issue (briefly!) if they wish. Finally, they are asked to tell us about something that brings them joy.

A slide presentation, handouts, analogies, examples and discussions are used to facilitate the understanding of the following concepts:
· What education about pain can do for patients with pain
· Pain terminology
· The nervous system and mechanisms of persistent pain
· How pain is influenced by our emotions, attitudes, beliefs and behaviors
· Strategies to improve quality of life when living with persistent pain
· Resources available to help patients in our clinic and our community.

We emphasize the role the patient can play by discussing Stages of Change, and how attitude affects health. The handouts for PEP Session #1 include information to help patients understand what they can expect to gain by better understanding persistent pain.

Handout Sample:
Why Try to Understand Persistent Pain? (From: The Chronic Pain Control Workbook 2nd Ed., E. Mohr Catalano, K.N. Hardin, MJF Books, New York NY, 1996. ISBN: 1-56731-210-1)

People who have learned more about persistent pain and how to deal with it have been able to do the following:
–   Put the pain in perspective.
–   Relax away some or all of the pain.
–   Make new decisions based on changes the pain has caused in their lives.
–   Set realistic goals.
–   Minimize the disruption the pain has caused in their lives.

All pain is real pain.

Each person’s pain is unique.
You cannot prove that you have pain.
All pain experiences are a normal response to what your brain thinks is a threat.
Real pain can exist without any damage to the tissues.
The construction of the pain experience in the brain relies on many sensory cues.
Pain is a very complex electrical and chemical response.
The brain interprets sensory information. It can intensify, act upon, or cancel danger signals coming from the body.

The intensity of pain is not necessarily related to the severity of the injury:

Remember that people with very damaged bodies have been able to run from danger or rescue others while experiencing no apparent pain.
People can experience pain in limbs that no longer exist.

The Persistent Pain Mechanism:

The brain gets excited if any part of the brain thinks we are in danger of being hurt. Pain signals are turned up to get us to respond to a perceived threat. The pain is REAL. Your central nervous system is increasing the danger message based on many factors.

Your pain can be worse depending on:

* Negative thoughts: anger, depression, fear, stress, painful memories, negative attitudes and beliefs.

* Physical state: fatigue (lack of sleep), hunger, cold, heat, noise…

The brain controls pain, regardless of what is happening to the body.
You can experience NO PAIN with extreme tissue damage.
You can experience extreme pain with no tissue damage.

Examples are given to show patients that the brain does not always see things accurately – eye tricks / illusions are useful in this demonstration of how the brain can misinterpret reality. The important message is reinforced: their pain is real, but may not be related to tissue damage. It may be related to an over-protective autonomic nervous system response.

Session #2 focuses on sleep and relaxation. Patients are asked to fill out a brief sleep questionnaire as a catalyst for questions and discussion.

Sleep Questionnaire:

1.     How well did you sleep last night?

2.     When you don’t sleep well, what is your pattern?

a.    Can’t get to sleep
b.    Keep waking up
c.     Wake up way too early and can’t get back to sleep
d.    Other?

3.     When you sleep well, what is it that helps you sleep better?

4.     When you sleep poorly, what are some of the reasons you feel this happens?

5.     In the space below, list some of the ideas you will try in order to improve your quality of sleep:

Next, we discuss factors affecting quality of sleep, and supply a list of practical solutions to sleep problems. These range from managing medications that might affect sleep, to having the appropriate mattress, pillow, and sleeping environment. Relaxation strategies are discussed and practiced (deep breathing techniques, simple stretches, tense-relax, etc.). The clinic loans out a range of relaxation CDs and also has them for purchase. Patients find these very useful.

Session #3 deals with Humor for the Health of It, and Physical Activity. Handouts list the healthful benefits of a sense of humor and a positive attitude. Patients are treated to a slide show that includes lots of laughs, and a mini Laughter Yoga (www.laughteryoga.org) session. We discuss the importance of physical activity, how to get started, and how to stay below the ‘pain radar’ with exercise sessions. Whenever possible, persistent pain patients are assigned warm water exercise as part of their treatment plan.

Patient feedback (questionnaires) on the PEP program has been excellent. Many say the 3 short sessions have helped them understand and cope with their pain better than any previous information or intervention. For many patients, the persistent pain experience is a long journey. The PEP sessions have proven to be beneficial to patients on the road to better quality of life.

References / Resources:

Butler, D., Moseley, L., Sunyata, Explain Pain, Noigroup Publications, Adelaide Australia, 2003. ISBN: 0-9750910-0-X
Catalano, E.M., Hardin, K.N., The Chronic Pain Control Workbook 2nd Ed., MJF Books, New York NY, 1996. ISBN: 1-56731-210-1
iPain101 – available on iTunes – a great little app (free) of the book, The Pain Truth…and Nothing But! By Dr. Bahram Jam. The book and affordable, patient-friendly booklets are available for purchase: www.aptei.com
Suggest patients look up ‘relaxation’ videos on youtube. These free videos offer soothing music + visuals to suit every taste.
Patterson, D., Pearson, N., Know Pain Seminar (2008) and workshop (2009)
Pearson, N., Understand Pain, Live Well Again: Pain Education for Busy Clinicians and People with Persistent Pain, Life is Now, Penticton B.C., Canada, www.lifeisnow.ca, 2007
Australian Youtube video briefly, but effectively explaining persistent pain: http://www.youtube.com/watch?v=4b8oB757DKc&feature=youtube_gdata_player