Download What Is Pain?

Durango Psychological Associates, LLC
ChiWalking and Pain
Ed Cotgageorge, Ph.D., ABN
Judith Vanderryn, Ph.D.
Overview
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1. What is pain?
2. Types of pain.
3. Biopsychosocial approach to pain
4. Things to watch for when working with
folks with chronic pain .
5. Why exercise?
6. Pain management with ChiWalking –
considers for program development
What Is Pain?
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Pain is the body's natural response to harm.
Pain occurs when special pain receptors at
the end of the nerves, called nociceptors, are
turned on because of an illness or injury or
because chemical changes within the body
indicate that tissues are being damaged.
When a nociceptor is turned on, a signal
travels through the spinal cord to the brain,
which recognizes the signal as pain.
Nociceptive pain
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Nociceptive pain is caused when special nerve
endings—called nociceptors—are irritated. Nociceptive
pain is the type of pain you feel when you burn yourself,
twist your ankle, or stub your toe. It is a dull or sharp
aching pain, and it can be mild to severe. This type of
pain can usually be controlled. Nociceptive pain can be a
temporary condition, such as when you have a sprained
ankle, but it can also be a chronic condition. Cancer pain
and arthritis pain are common types of chronic
nociceptive pain.
Neuropathic pain
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Neuropathic pain is caused by a malfunction of the
nervous system due to an injury or an illness.
Neuropathic pain can be a sharp, intense, shocking, or
shooting pain. It is also very stubborn in that it does not
usually respond as well as nociceptive pain to standard
pain therapies, such as over-the-counter pain
medications (for example, aspirin or ibuprofen) and
prescription pain medications.
Biopsychosocial Model of Chronic Pain
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Concepts/Definitions
Assessment/Evaluation
Treatment Interventions
Why this approach?
Basic Elements of the Biopsychosocial Model
Sensory
This refers to the physical sensations which make up the experience of pain.
They can be described on four key dimensions: 1) location - where on your
body the pain is experienced, 2) intensity - how intense the pain is (e.g., ranging
from mild to excruciating), 3) quality - the qualitative nature of the sensations
(e.g., dull, aching, sharp, burning, stabbing), and 4) time - how the sensations
vary over time.
Emotional
This includes all of the emotional states which accompany the experience of
pain, as well as the effects of pain on your life. Examples include fear, anxiety,
worry, discouragement, depression, despair, guilt, anger, and irritability.
Mental
This includes awareness of pain, focus of attention, memories of pain and other
experiences, expectations regarding the pain condition and your ability to cope
with it, perceptions of ongoing life events, thoughts which accompany emotions,
decision making processes, attitudes toward yourself and others, etc. Another
word which we use for mental is cognitive.
Basic Elements of the Biopsychosocial
Model
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Behavioral (Actions)
This includes all the things that you actually do in response to your
experience of pain, ongoing emotional states, and the consequences of
pain on your life. It also includes physical activities and social
interactions which can affect your pain intensity as well as influence
your thoughts and emotions.
Physical environment
This includes all aspects of the physical environment which affect your
awareness of pain or ability to cope with pain. Examples may include
weather conditions, housing conditions, physical objects such as beds
and chairs, availability of money and other material resources, means
of transportation, etc.
Social environment
This refers to all individuals who can affect and are affected by your
pain condition. It includes family and friends, medical care providers,
representatives of the disability compensation system, etc.
Basic Elements of the Biopsychosocial
Model
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Interactions
It is important to understand that each of these factors cannot be considered in
isolation. That is, each element interacts with and is affected by each other
element.
Vicious Cycles
One unfortunate way in which these elements often interact is to create vicious
cycles. For example, pain sensations (Sensory) often result in decreased
physical activity (Actions). Decreased physical activities can create feelings of
depression (Emotional) and decreased self-worth (Mental). The depression can
lead to decreased motivation and initiative and even less activity (Actions).
Decreased activity, accompanied by withdrawal from other people (Social),
leads to even more depression (Emotional), preoccupation with negative
thoughts (Mental), and increased awareness of pain (Sensory).
Positive Cycles
Fortunately, the interactions among these elements can work in a positive way
as well. Even though it is difficult to directly control your painful physical
sensations and negative emotional reactions, you can significantly affect both by
altering your thoughts and actions.
Chronic pain: A biopsychosocial
disorder
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Overall, the research literature suggests that psychological
difficulties are common among patients with pain.
Left undetected and untreated, these difficulties may impede a
patient’s progress in treatment and lead to long-lasting
symptomatology.
Among those who report pain and injury, psychosocial factors
may play a major role in delayed recovery.
One study of psychosocial factors demonstrated an ability to
accurately predict delayed recovery for patients suffering acute
pain 91% of the time without using medical information.
Another study found that psychosocial factors play a dominant
role in surgical outcome.
Lastly, in a World Health Organization study of 25,916 medical
patients from around world, psychological factors were found to
be a stronger contributor to disability than was disease severity.
Biopsychosocial Model
Assessment
The pain is in my back not my mind.
Psychological Screening
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RISK FACTORS FOR CHRONIC PAIN
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Pain duration longer than two years.
Multiple invasive procedures
Prolonged recovery
Job dissatisfaction
History of emotional or physical trauma
History of sexual abuse
Low levels of activity, excessive pain behaviors, poor family response
Negative or fear based beliefs about pain and activity, Pre-injury
mood , anxiety, substance abuse, personality disorder
Psychological Screening
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POOR OUTCOME INDICATORS
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Low levels of activity
High degree of and increases in pain behaviors
Fear based beliefs that pain is harmful or out of control
Presence of hostility, anger or withdrawal
Poor coping strategy use
Psychological Screening
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TREATMENT RECOMMENDATIONS
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Behavioral
Specific
Procedural
Time limited
Why exercise?
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It is postulated that retraining the nervous
system to reestablish more neural
connections through the use of exercise and
psychologic treatment can effectively
diminish chronic pain.
First-Tier Pain Therapies
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Exercise programs. One of the first treatments for
chronic pain may be light exercise, such as walking.
Exercise stimulates the release of the body's natural
pain relievers called endorphins. It promotes flexibility,
strength, and endurance, and it helps reduce stress.
Exercise can also strengthen unused or weak muscles to
compensate for an overworked muscle that is causing
pain.
First-Tier Pain Therapies ,
Continued
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Over-the-counter pain medications.
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Rehabilitative therapy
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Transcutaneous electrical stimulation
(TENS).
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Cognitive and behavioral modification.
Biopsychosocial Treatment
Breaking Down Myths
 Pain is always a reliable signal of physical damage and injury.
 When no clear physical damage is found by diagnostic
procedures, pain must be imaginary.
 Chronic pain that does not respond to standard treatment
should not be taken seriously.
 There is a pill for every ill.
 Pain is a signal to stop moving.
 If you have had pain for a long time and doctors have told you that
they have “done all they can,” your situation is hopeless.
Motivation to Change
Pre-contemplation, contemplation, plan, action.
Treatment Interventions
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Behavioral
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Becoming your own pain expert
Activity , different definitions of rest, pacing
activity
activity
rest
rest
activity
activity
rest
rest
Treatment interventions, continued
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Behavioral
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Relaxing
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Sources Stress =sensory overload, emotional
vulnerability, uncertainty and fear , loss of concentration,
sleep problems, digestive problems, chronic fatigue.
Typical stress reduction. Alcohol and other drugs,
television and reading, computer games and the
Internet.
Preferred stress reduction. Biofeedback , Relaxation
exercises, controlled breathing, attention diversionmeditation and prayer, create a safe home environment,
learning to enjoy food, enjoying other people .
Treatment interventions continued
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Sources of FATIGUE
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Emotional tiredness
Physical tiredness
Nutritional tiredness
Treatment interventions, continued
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Physical tiredness
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Pain---Inactivity-----Fatigue--Inactivity--Pain
Be realistic. Do not expect changed occur rapidly.
Weight loss , dietary and nutritional supplements , good food choices.
Sleep hygiene
Pacing
Biofeedback
Progressive relaxation
Distraction
Passive modalities –massage , medications .
Treatment interventions, continued
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Emotional tiredness
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Relationships –communication skills, sharing with
family and friends.
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Other people’s pain is not interesting
Other people have their own problems
Pain causes negative feelings
Getting and giving respect
Assertive , not assertive , and aggressive
behavior
Intimacy
Treatment interventions, continued
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Changing behavior
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Reinforcement –positive, negative, punishment,
neglect. Doctors often reinforced pain by paying attention to
increased pain reports and not acknowledging decreased pain reports.
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Preparing for behavior change.
Patients often feel
punished because behavior change almost always includes a
certain amount of discomfort or emotional stress. Research has
shown that consistent change does not occur for about six
weeks.
Treatment interventions, continued
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Changing Thoughts and Feelings
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Cognitive distortions –blaming, should/musterbating,
polarized , catastrophize, emotional reasoning, control fallacy,
entitlement fallacy, overgeneralizing, mind reading .
The ABCD Model –
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Activating event
Belief
Consequence
Dispute
Treatment interventions, continued
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Maintenance
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Bring more physical activity or exercised your life
Ensure sufficient relaxation
Bring and more diversion and fun into life
Setbacks /Flair-ups
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Change activity–rest cycle
Cut back on physical activity
Increase activities gradually
Practice relaxation and breathing exercises twice as much as before
Increased positive thoughts
Distraction, imagery
Talk to family and friends about your plan.
Types of exercise Recommended by
American Pain Foundation
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Aerobic
Flexibility
Strength
Choosing an exercise and ChiWalking
Principals
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Choose exercises that can be incorporated into your daily routine
and that you enjoy. Many forms of exercise are fun and help you
enjoy the outdoors or time with a partner or friend. (Mindful practice)
Make exercise a priority by setting a schedule and sticking to it.
Eventually, exercise will become a routine in your life – something
that you'll miss if you skip a day.( Make a choice)
Ask your doctor about appropriate exercises and activities for your
situation. (Get aligned)
Set appropriate goals. No goal is too small – visiting friends or
walking around the block may be appropriate goals, depending on
your pain and physical condition. (Gradual Progress)
Choosing an exercise and ChiWalking
Principals
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Be gentle to yourself, both physically and mentally. Don't
beat yourself up if you miss a day or a week or a month.
Each day is a new day and you can start again.
(Nonidentification)
Listen to your body and don't force it to do something
that is painful, such as sitting cross-legged for
yoga.(Body Sensing)
American Pain Foundation
recommends:
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T'ai Chi Chih
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Need we say more?
One way of approaching program
development for chronic pain
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Be aware of Biopsychosocial factors
Know contraindicators
Understand a little bit about pain
manifestations.
 Go
slow – really slow, has
slow been mentioned???
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Thank you.