All persons with a chronic pain condition experience fluctuations in their pain intensity. Pain flare-ups refer to those times when your chronic pain is more intense than usual. Thinking in terms of the common 0 to 10 pain intensity scale, a flare-up usually refers to episodes in which the pain is at a 7 or higher. These episodes of intense pain may be experienced in various ways such as "muscle spasms", "jolts of electricity", "sharp, jabbing sensations", "cramps", etc. Chronic pain flare-ups may also last for varying periods of time, ranging from a few seconds to several hours. Unfortunately, if the intense pain is prolonged, it usually becomes a time when you become most upset or discouraged. Obviously, you are most likely to use pain medications during chronic pain flare-ups. While use of pain relievers, such as the opioids, can be quite helpful or even necessary, it is also wise to have available a number of constructive non-pharmacological strategies. In other words, rather than relying solely on pain medications, we recommend having a variety of self-management pain control techniques at your disposal during pain flare-ups.
The ideal way to manage episodes of intense pain is to prevent them from occurring all together. In order for prevention to work, you must first be able to identify pain activating triggers. Pain activating triggers refer to any situation or activity that tends to push your pain intensity level up. Nearly everyone with chronic pain has pain triggers. However, in order for prevention to work, the pain activating trigger must be under your control, at least to some degree.
One relatively common type of pain activating triggers that is largely uncontrollable is certain weather conditions (e.g., cold damp weather, changes in weather conditions). Although weather conditions may serve as pain activating triggers, they have little value in terms of prevention, since you cannot control the weather.
There are two major categories of pain activating triggers that are most relevant to prevention among persons with chronic pain. The first category refers to physical activity/inactivity triggers. Common examples of physical activity triggers include:
· Staying in one position too long (e.g., sitting or standing for an extended period of time).
· Certain repetitive movements that are performed too long.
·
Movements that put excessive strain on
vulnerable pain areas (e.g., lifting or pulling a heavy object).
A mistake that some people make in their efforts to avoid these physical activity triggers is to give up nearly all physical activities. Unfortunately, this is self-defeating because it leads to further physical deconditioning. The goal is to keep physically active while staying within your physical limitations.
The second category of pain activating triggers refers to emotional stress triggers. Of course it is not possible to completely eliminate stress from your lives. Therefore, more reasonable goals are to minimize or prevent unnecessary stress, or find better ways to cope with your stress.
In addition to working with pain activating triggers, another form of prevention involves identification of early warning signs that a pain flare-up is coming on. Many persons with chronic pain find that they can sometimes detect certain physical signs (body sensations) in advance of a full blown pain episode or flare-up. When this occurs, many try to ignore these sensations and press on with whatever they are doing, or they engage in anticipatory catastrophic thinking (e.g., "looks like I'm really going to have a bad episode today and there's absolutely nothing I can do about"). A better strategy that some have been able to use effectively is preventive coping. This strategy involves using the early warning physical signs as a reminder to do some type of relaxation procedure such as deep breathing exercises, relaxing specific tense muscles, modifying the warning signals with mental imagery, or doing a hand warming exercise to prevent a full migraine attack.
Not all intense pain episodes are triggered, and not all triggered pain is controllable. Furthermore, since no one is perfect, there will be times when you will fail to prevent an episode of intense pain that could have been prevented. Constructive coping refers to taking whatever steps you can take to manage the intense pain that are beneficial in both the short and long run. Getting intoxicated with alcohol may help reduce the pain in the short run, but it is not constructive since it has negative consequences in the long run.
By far, the most commonly used technique for coping with acute pain flare-ups is to take pain medications. In fact, many persons with chronic pain have told us that, when their pain reaches a high level of severity, they have no choice but to take a opioid pain reliever. They have in effect convinced themselves that there is absolutely nothing they can do on their own to achieve any pain relief. While taking pain medications may be the simplest and sometimes the most practical coping alternative, the self-management approach looks for constructive non-drug coping alternatives. Even if you do use pain medications, constructive coping alternatives may enable you to decrease the amount of medication you require.
First, it is important to have realistic goals in mind when you are experiencing a flare-up. Obliterating pain completely from your mind is probably not a realistic goal. If you take your pain medication as prescribed, it probably won't make the pain go away entirely. Following are some potential realistic goals:
· Decrease the intensity of the pain sensations
· Decrease your awareness of the pain sensations
· Alter (reinterpret) the meaning of the pain sensations
·
Survive the pain flare-up episode without making
it worse
Constructive coping methods fall into two general categories. The first category refers to action strategies. Some of these methods are obvious, while other may require some experimentation. Examples of physical coping activities that may relieve some of the intense pain include:
· change your body position
· rub or massage the painful area
· do certain stretching or range of motion exercises
· apply heat (wet or dry) to the painful area, or soak in a hot tub of water
· apply freezing cold (e.g., ice packs) to the painful area
· apply an electrical nerve stimulator TENS Unit
· get involved in a distracting activity that is not too physically demanding
· go for a walk
· get involved in a conversation with someone where you talk about something other than pain
·
use special breathing techniques such as the
controlled panting used in prepared childbirth training to help cope with
intense labor pain
The second category refers to mental coping strategies. This refers to anything you can do at a mental level to cope more effectively with the chronic pain flare-up while it is occurring. At a general level, we can identify two basic mental approaches:
· Distraction strategies
·
Mindful awareness and constructive response
strategies
Distraction refers to anything you can do to shift some of your awareness of pain on to something else. Rather than allowing pain to totally dominate your mind, it may be possible to shift some of your awareness elsewhere. Distraction can involve doing some activity (action strategy) or it may be purely mental. This might involve imagining that you are doing some relaxing or enjoyable activity (e.g., going fishing) or stimulating activity (e.g., meeting a new romantic or sex partner). They can be realistic activities (e.g., preparing a shopping list), or they can be entirely fanciful (e.g., imagine that you just won the lottery and are trying to decide what you would do with all the money). Some people like to design, assemble, or construct something in their minds (e.g., designing the floor plan for a dream house).
While distraction can be very beneficial, we also recognize that when pain is very intense, distraction is much more difficult. In fact, it may seem nearly impossible. For that reason, we also have to consider mindful awareness and constructive response strategies. Mindfulness awareness means that you mentally acknowledge the pain, including where it hurts and what it feels like, but do so in a way that does not contribute to further suffering. As mentioned earlier in this book, suffering can result when you fight and resist pain. We recognize that increased physical tension and mental distress may seem like an automatic and inevitable reaction to intense pain. However, it is possible to learn how to bring mindful awareness to the pain without the automatic physical and mental reactions which tend to increase suffering.
Following are some mindful awareness and constructive
response strategies:
Encouraging
self-reminders refer to statements that you make silently to yourself that
will help you to better cope with or endure the intense pain that you are
experiencing. Reminders should be realistic in nature. Saying to yourself, "I feel
great," or "I am not feeling any pain" probable won't work
because they are obviously untrue.
Saying to yourself, "I can survive this," or "It will
eventually ease up" is much more realistic. Positive reminders will probably have to
be repeated to yourself over and over again while you are in the midst of the
intense pain episode. Use of such
reminders can be a powerful tool to help you through even the worst of pain
crises. Remember that people have
survived extremely adverse circumstances like being in a POW camp or going
through torture by using this tool.
It might be helpful for you to make a written list of positive
self-reminders and then refer to them when you are experiencing a chronic pain
flare-up.
Prayer and spiritual approaches may be of significant
benefit for those who are religiously or spiritually inclined. Some find that asking God for strength
to help endure the pain episode is
more beneficial than asking God to make the pain go away. Others find it beneficial to recite
verses from the Bible, say the rosary, or read passages from inspirational religious
literature. Earlier in this book, the practice of spiritual surrender was
briefly discussed as a paradoxical way of responding to uncontrollable adverse
situations like intense pain episodes.
Alter the meaning of the chronic pain flare-up. Whenever pain is especially intense, there is a natural tendency for the mind to try and make sense out of what is going on (i.e., “what does this mean, why am I having this severe pain right now?” Most often, the meaning is very negative (e.g., “something is terribly wrong with my body,” “the doctors are not treating me the way they should,” “it’s all my fault for physically overdoing it “). These negative meanings can add to the suffering which accompanies the pain flare-up. Anything you can do to give the pain flare-up a more positive or less negative meaning will be of value. For example, any of the following three views (altered meanings) may be helpful:
· Pain as a teacher.
· Survive the storm.
·
Outwit the pain enemy.
Pain as a teacher. The intense pain which you are
experiencing right now represents a message from your body, telling you
something that you need to pay attention to. Perhaps your body is telling you that
you pushed it too hard and exceeded your limitations. Perhaps your body is telling you that
your stress level is out of control.
What can you do right now to heed the messages that your body is giving
you?
Survive the storm. Being in the midst of an intense pain
episode is like being in the middle of a storm. Perhaps you received a storm warning, or
perhaps it came on suddenly. What
can you do about it? You certainly
can't stop the storm. Trying to
fight the storm will only make you feel worse. At least storms are temporary, they
eventually ease up. What can you do
right now to survive the storm and minimize damage? What specific thoughts and images can
you think of to weather the storm more effectively? Can you use your imagination to alter
the way your mind perceives the pain? What encouraging thoughts and
reminders can you give to yourself right now that will help you to hang in
there? Can you focus your mind away
from the storm and think about something else?
Outwit the pain enemy. You feel like your under attack by a powerful enemy. Since you can't defeat the enemy right now, the best you can do is to keep it from defeating you. What is the pain enemy trying to do to you? Is it trying to convince you that you are totally under its power and that there is absolutely nothing you can do about it? Is it trying to get you feeling so helpless and hopeless that you see no solution but to end it all? Is it trying to make you into a drug addict or alcoholic? Is it trying to cut you off and isolate you from other people and destroy your relationships with family and friends? Is it trying to turn you into a bitter, ugly, nasty person whom no one will want to be around?
What can you do right now to outwit the pain enemy and keep it from being victorious? Remember that the enemy will eventually ease up on its attack. What defensive weapons can you use to hold the enemy at bay until it backs off and stops attacking you?
Aside from these
three suggestions, you may be able to find other positive meanings to your
pain. Many have been able to reduce their suffering by finding positive meaning
when faced with acute pain. Dr. Beecher, a famous surgeon, noted a long
time ago that men who suffered physical injuries during World War II combat
reported less pain (and less need for pain medications) than those who suffered
comparable injuries in non-combat situations or following surgery. Dr. Beecher suggested that those who had
been wounded in combat were able to attach more positive meanings to their
injuries (e.g., it happened in defense of our country, it would enable one to
leave the battle field and possibly return home) and, as a result, experienced
less pain. Women who undergo
intense labor pain are able to better endure the pain because of the positive
meaning attached to the experience (i.e., it is a natural and inevitable part
of the process of bringing a new baby into the world). Is there anything that you can think of
that might give your pain experience a more positive meaning? If so, they can be used as encouraging
self-reminders during the intense pain episode.
Pain modification
imagery refers to use of mental images that acknowledge the pain but then
aim at modifying or transforming the way the pain is experienced. As mentioned earlier in the
self-hypnosis section, it may be possible to use your imagination to alter the
specific pain sensations. Burning pain can be cooled, sharp pain can be dulled,
tight or squeezing pain can be loosened.
You may be able to mentally move the pain to a different location either
inside the body or outside the body, or you may imagine you body’s own
defenses and healing forces coming into play (e.g., mobilizing your
endorphins).
Detached (non-judgmental) pain awareness is a mindfulness
technique in which you deliberately focus your mind on the specific pain
sensations, but in a very analytical and detached manner. That is, you maintain full and complete
awareness of the various pain sensations (specific qualities, precise
locations, fluctuations over time) without getting caught up in all of the negative
thoughts and feelings that usually accompany intense pain. With this technique,
you simply bring your awareness to what is at the present moment without reacting to the pain in a negative
manner. Often, this technique requires considerable familiarity and experience
with mindfulness meditation.
Radical acceptance
is a fall back when all else fails. It can be used when it seems as though
you’ve tried everything and nothing works. Radical acceptance means
letting go of all efforts to fight and resist the reality of the pain you are experiencing.
The term “radical” means that acceptance has to be complete and
come from deep within your being. Radical acceptance refers to accepting the
pain in the moment it is actually occurring. There is no need to accept future
pain or past pain, only the pain that you are experiencing right now. Getting upset and trying to fight the
reality of pain only increases suffering and misery. Acceptance has nothing to do with liking
or approval. It just means accepting a situation over which you have no direct
control. Sometimes, it is helpful to remind yourself that, “pain is
inevitable, suffering is optional,” or “suffering represents the
inability to accept pain.”
After the pain flare-up is over
Once you have survived the intense pain episode using your
self-management tools (weapons), you should pat yourself on the back ("I
knew I could do it," "I made it on my own without turning to alcohol
or drugs," "I survived the storm (or enemy attack) without getting
wiped out," "I did a good job," etc.).
Make a list of pain management tools (or weapons)
When you are in the midst of an intense pain episode, it may be hard to think of constructive coping alternatives. It is much better to plan in advance how you will handle an intense pain episode when it occurs. No single method will work every time or be appropriate for every situation. Make a list of specific pain management tools or weapons. Carry this list with you or keep it posted at home. Then, whenever you are in the midst of intense pain, you can take a look at the list and try the various alternatives.
Following is a worksheet for you to write down things that
you can do or think about when you are experiencing a pain flare-up. Think of this as your "Pain
flare-up survival plan."
Please try to be specific as you make your list. You should also think of this as an
ongoing list that you can keep adding to as you discover new techniques to cope
with the pain.
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Be Patient With
Yourself |
No one learns to successfully self-manage pain flare-ups overnight. It takes time and practice. Fortunately, each time you are successful, the more likely it is that you will experience success the next time you experience a pain flare-up.
Also keep in mind that no one can develop confidence in
their pain coping tools until they have been put to the test. Each time you
experience a pain flare-up, you have an opportunity to utilize and perfect your
pain coping tools.
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Practice and Success
Build Confidence |
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MY PERSONAL PAIN
FLARE-UP SURVIVAL GUIDE: THINGS TO DO OR THINK ABOUT WHEN I AM EXPERIENCING PAIN FLARE-UPS |
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· Apply heat or cold therapy to the affected area, depending on what gives you better relief.
· Warm showers or bath, tend to be very soothing. They also help relax tight muscles.
· Tylenol (acetaminophen). Do not take more than 4000 mg in a 24 hour period. Beware if you have liver problems. May take in addition to NSAIDs (non-steroidal anti-inflammatory drugs). (Check with your primary care physician)
· Motrin (ibuprofen). May take up to 800 mg, up to three times a day. Beware if you have kidney problems, are taking other NSAIDs, have ulcers, or take anticoagulants. May take in addition to Tylenol. (Check with your primary care physician)
· Steroid pack. Do not take with other NSAIDs. Beware if you have congestive heart failure, or taking anticoagulants. (Check with your primary care physician)
We recognize that, if given a choice, most chronic pain
sufferers would prefer medical management over self-management. After all,
medical management requires relatively little effort on your part. With medical
management, all you have to do is do is passively go along with whatever the
doctor or other health care professional tells you to do whether it be taking
pills or submitting to passive physical procedures. When medical management
works, all seems well and good. Of course, unlike self-management, you can't
personally take any credit for its effectiveness even when it does work.
Unfortunately, when pills and passive procedures don't work, you are often left
feeling even more frustrated and discouraged.
Medical science together with the pharmaceutical industry
are constantly looking for better and more effective ways of treating chronic
pain. As indicated in the last chapter, we can all hope that these efforts will
ultimately be fruitful. Meanwhile, you are left with the reality that your
chronic pain persists despite the many medical management procedures which have
been offered and tried.
Throughout this handbook, we have repeatedly emphasized the importance of mental and emotional factors in chronic pain. The vast majority of medical management approaches view chronic pain as a purely physical phenomenon while ignoring the importance of psychological factors. Self-management, on the other hand, recognizes that chronic pain always involves physical, psychological, and social factors. Even common medical procedures such as taking medications or receiving injections involve psychological factors. It has been estimated that anywhere from a third to a half or more of the therapeutic efficacy of pain medications is due to the placebo effect, i.e., your belief or expectation that you will obtain pain relief as a result of taking a pill. Self-management aims at turning the healing power of such positive beliefs into greater confidence in yourself rather than in drugs.
Rather than looking for cures or passive procedures that increase your dependence on medical professionals, self-management emphasizes constructive coping. Coping requires some effort on your part. Coping often involves the acquisition of skills and, like most other skills acquired during the course of life, it requires learning and practice. Whenever your face a problem in life and someone else comes along and solves the problem for you, you feel a certain sense of relief. But consider how much better you feel when you solve the problem on your own by making use of knowledge and skills that you have personally acquired. In addition to learning specific skills, coping may involve making use of resources in your natural environment. Drawing upon help and support from family and friends is an example of using coping resources. Other valuable coping resources may be found in your broader community. In my opinion, the primary advantage of self-management over medical management when it comes to chronic pain is that it fosters and reinforces healthy self-reliance rather than dependence on professionals.
Most of the chronic pain coping skills and resources discussed in this Handbook can be divided into one of three categories: physical focused coping, emotion focused coping, and problem focused coping.
Physical focused coping refers to activities on your part which can reduce or alter the physical (sensory) aspects of chronic pain. Examples of physical coping skills include the following:
· Stretching exercises, yoga postures
· Muscle toning and strengthening exercises
· Aerobic exercises
· Maintaining a healthy diet, Losing excess body fat
· Refraining from unhealthy habits such as use of tobacco, alcohol abuse, overuse of caffeine, excessive inactivity
· Sensory stimulation techniques (e.g., use of massage, heat, cold, vibration, electricity, etc.)
· Activity pacing techniques
· Improving your posture, normalizing body movement patterns, using good body mechanics
· Time-out relaxation techniques
· Mindfulness meditation
· Pain flare-up prevention techniques
· Pain diversionary activities
·
Mental techniques which alter the interpretation
or meaning of pain sensations
Emotion focused coping is used to manage all forms of emotional distress including feelings of depression, anxiety, frustration and anger. As discussed earlier, emotional distress usually compounds the problem of chronic pain. Examples of emotion focused coping methods include:
· Use of the signal breath during times of emotional stress and tension
· Time-out relaxation or meditation techniques
· Self-hypnosis techniques
· Positive affirmations (self-reminders)
· Religious and spiritual practices including prayer, reading religious literature, attending church or synagogue, talking to a clergyman, surrendering problems to God or higher power, etc.
· Identifying and modifying irrational thoughts and cognitive distortions
· Cognitive reframing (viewing your problems in a different and more positive light) and perspective taking (e.g., viewing your problems in relation to others who have it much worse off than you)
· Developing more positive attitudes such as healthy optimism, empathy for others, feeling grateful for your blessings (attitude of gratitude), understanding the connectedness of all persons and living things
· Working on your inner character such as becoming more patient, tolerant, and compassionate toward others
· Making use of available social supports (friends and family)
· Seeking professional help when needed for significant emotional problems such as depression, anxiety and difficulties managing anger
· Use of assertiveness and effective communication skills including active listening
· Healthy use of acceptance, reframing, and redirection
· Developing a healthy sense of humor
·
Seeking opportunities to experience positive and
uplifting emotional states
Problem focused coping may be used for addressing problems stemming directly from your chronic pain condition or other life problems which may have little to do with your pain. Examples of problem focused coping approaches include:
· Taking personal responsibility for doing something about your problems rather than simply blaming other people or external circumstances
· Setting realistic and achievable (SMART) goals
· Using relaxation techniques to gain greater mental clarity
· Use of constructive problem solving techniques such as the SODAS described earlier
· Identifying resources for obtaining additional information (e.g., talking to knowledgeable people, going to a library for information, searching the Internet)
· Acquiring new knowledge and skills either on your own or with the assistance of knowledgeable others (e.g., taking classes, going to school); the new knowledge and skills may be work related or simply for fun, enjoyment or personal growth
· Taking constructive action rather than procrastinating
Note that a particular coping method, such as time-out
relaxation, can be used in more than one category depending on how and why it
is used. The ultimate success of chronic pain self-management requires you to
develop several skills in each of these major coping areas.
After considering all of the principles and techniques
discussed in this handbook, list the coping methods that you would like to work
on to improve your own ability to self-manage chronic pain and other life
problems.
The word "coping" typically means dealing with or managing problems and difficulties. However, a review of the coping methods listed above clearly indicates that several of them are concerned with much more than managing pain and other life difficulties. Improving your character, developing more positive attitudes, acquiring a more healthy and enriching philosophy of living, and spiritual growth all go beyond simply coping with life problems.
One personal growth ideal which I find especially relevant and worth pursuing is that of serenity. This concept has been used to characterize peace of mind, often in the face of difficult and challenging life circumstances. In article by Roberts and Cunningham (1990) in Educational Gerontology, the following 10 characteristics were used to define serenity.
1. The ability to detach from desires and/or emotion and feelings
2. The ability to be in touch with an inner haven of peace and security
3. A sense of connectedness with the universe
4. A trust in the wisdom of the universe
5. The habit of actively pursuing all reasonable avenues for solving problems
6. An ability to accept situations that cannot be changed
7. A way to give unconditionally of one's self
8. Forgiveness of self and others
9. The ability to let go of the past and the future and to live in the present
10.
A sense of perspective as to the importance of
one's self and life events
The term "detachment," used in the first characteristic above, does not mean being oblivious to life problems or apathetic disregard of such problems. Rather, with detachment there is a recognition of problems, including chronic pain and disability, but in a manner that keeps them distinct and in proper perspective. With true serenity, chronic pain and disability are recognized as part of your lot in life, but they do not define your existence.
As suggested in the second characteristic above, it is
possible to have chronic pain and yet be in touch with an inner haven of peace
and security. As discussed in this Handbook, relaxation, meditation, and
visualization exercises may be useful means of accessing this inner haven of
peace.
Some may wish to substitute the word "God" or
"higher power" for "universe" in the 3rd and 4th
characteristics above. Keep in mind that serenity is a key component of
spirituality. It may or may not be associated with particular religious beliefs
and practices. The 5th and 6th characteristics of serenity highlight the
importance of maintaining an active problem solving problem orientation when
possible, while also accepting those situations which cannot be changed.
The 7th and 8th characteristics of serenity involve a
positive and accepting attitude toward oneself and others. Of course it is
difficult to feel positive and accepting of others when you have negative
attitudes about yourself. As discussed in the chapter on self-managing daily
physical activities, learning to accept and value yourself, despite having
chronic pain and disability, is an important goal of self-management.
Forgiveness of self and others, discussed in the chapter on anger, is also
important to counter feelings of resentment which sometimes accompany chronic
pain. As you learn to forgive and let go of past emotional pains, you will find
it easier to live more fully in the present (9th characteristic of serenity).
For those with chronic pain and disability, letting go of the past may also
involve letting go of idealized attachments to memories of one's life prior to
the onset of pain. Finally, the discussion on thoughts and feelings in the
cognitive therapy chapter repeatedly emphasizes the importance of maintaining a
sense of perspective on oneself and life events (10th characteristic of
serenity listed above).
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Serenity does not require the absence of pain and disability. Rather serenity involves being able to transcend one's pain and other life problems. |
Most important is the realization that achieving serenity
does require one to get rid of pain and other life problems. By making active
and regular use of all the tools discussed in this Handout, we believe that
serenity is possible despite having chronic pain and disability.