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11 Articles in Volume 14, Issue #1
The WHO Pain Ladder: Do We Need Another Step?
History of Pain: The Psychosocial Assessment of Pain
Lyme Disease: A Short Primer for Pain Practitioners
Opioid Prescribing Part 1: A Practical Guide to Appropriate Documentation
Pain, Impairment, Whiplash, and the New AMA Guides: What Clinicians Need to Know
The 5 Coping Skills Every Chronic Pain Patient Needs
Demystifying Benzodiazepine Urine Drug Screen Results
Practical Pain Management: The Nation’s Premier Teaching Journal for Pain Practitioners
PPM’s Editorial Board Weighs In on WHO Ladder
Are patients taking acetaminophen (Tylenol) at risk for developing serious skin conditions?
What are some home exercises and tips to help patients manage rotator cuff injuries and pain?

The 5 Coping Skills Every Chronic Pain Patient Needs

Pain management is like a 3-legged stool—interventions, medications, and psychological education and counseling. Without all 3 legs, the stool will fall.
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Psychologists and other providers often also address such issues as fear avoidance of pain, how in chronic pain “hurt does not mean harm,” and how a downward cycle of dysfunction and immobilization often is overlaid on chronic pain conditions. The sensation of pain usually means that there is bodily damage. A natural reaction to pain is to stop moving, a tactic that helps decrease the pain temporarily. But this stopping of movement can lead to more muscle contraction, altered body mechanics, increased pain, and more inactivity. This can become a downward spiral of inactivity and increased pain. Patients need to understand that with chronic pain “hurt does not mean harm.” The pain sensation is basically a false or over-amplified sensation and does not reflect new or more tissue damage. One important step for pain patients then is to realize that it is okay to move and to feel some pain. By slowly increasing movement, patients realize that the pain is indeed bearable and need not be avoided as much as they may have been doing. This can start a positive cycle upward of more activity and increased tolerance of pain. Addressing this and other issues surrounding a patient’s diagnosis and treatment plan are, for me, the first steps in creating a working treatment relationship and moving forward with the patient to address his or her pain.

The Second Skill: Accepting

How the patient thinks about his or her pain is critical to successful outcomes. “Catastrophizing”—the behavior of patients telling themselves that their pain is the worst imaginable, that relief is impossible, and that this is the worst situation of their lives—has been shown to be an important predictor of negative pain treatment outcomes.4 An important skill for the patient is be able to accept his or her situation and decrease their emotional struggle with the situation. This can be a tricky skill to discuss because it is not helpful for the patient to just give up and not put in any effort to deal with making his or her life better. What “acceptance” means is a worthy of discussion with every patient. Acceptance and having appropriate attitudes and expectations about chronic pain are central to cognitive-behavioral therapy (CBT), which is the most commonly used psychological therapy for pain patients and has been shown to be effective in treating chronic pain conditions.5 Acceptance and Commitment Therapy (ACT) also has been shown to be effective for chronic pain conditions.6 These treatments reflect the overall patient skill of what I have termed accepting.

Accepting is a major issue for all pain patients and will be a part of any treatment of chronic pain, whether one is a psychologist or not, and whether one is doing CBT or not. There are many counseling and motivational techniques that can help in this area, in addition to CBT and ACT. On a simple level, I tell many patients that the basic issue is changing from thinking “woe is me” or “why me” to “what now.” When a patient begins to focus on what he or she can still do and what role in life he or she will have from now on, then this reflects increased acceptance. One basic approach to foster this type of thinking is gratitude. By helping the patient focus on the skills and resources he or she still has, despite the pain, this can help refocus them from the loss to moving forward. While the patient’s “glass” may not be even half full, there is usually some amount of water left in the glass, and focusing on what is left and where to get new sources of water is a key skill for pain patients.

Avoiding “shoulds” is important (and is central to CBT). Many pain patients, and most of us as human beings, think with “shoulds.” “I should be able to help my family more,” “I should be able to work a full-time job,” “I shouldn’t have this much pain because I am so young,” and “ I should not let the pain get to me like it does” are common statements that pain providers hear routinely. Working with the patient to help them have appropriate and realistic expectations is important to any pain treatment. A patient’s level of acceptance will vary from day or day or even minute-to-minute, but it is important for a pain clinician to know where a patient is overall with respect to acceptance.

The Third Skill: Calming

Pain is meant to stimulate the body into action and to avoid danger. This is the well-known “fight or flight” response. The natural reaction of patients with pain is to be in a state of physiological arousal. The problem is that, because the pain is ongoing, the body can be damaged by this ongoing stress. Therefore, an essential skill for any pain patient is to learn how to calm the body down. I usually use the word “calming” rather than “relaxation” because the word “relaxation” has so many different meanings and uses in our culture that it can get hard to determine exactly what we are talking about.

There are a wide array of relaxation techniques that have been used in patients with chronic pain conditions: progressive muscle relaxation, mindfulness, guided imagery, yoga, tai chi, qi gong, and many more. In the past, I have found it difficult to know where to start in this area. In our practice, my colleagues and I differentiate 2 aspects of calming. We first talk about calming down the body’s stress reaction—decreasing stress. This is taught most easily by teaching the patient diaphragmatic breathing. Inhaling with the diaphragm rather than the chest and shoulders (ie, shoulder breathing) can be taught quickly and easily. To demonstrate the impact on the body, I have patients first count their breaths for a 30-second period and write down the number. Then we talk about diaphragmatic breathing and have them put their hand on their abdomen and feel what it is like to breath with the diaphragm rather than the chest. After only a few minutes of discussing this, I ask the patients to again count their breaths, and this time breathe with the diaphragm to the extent they can. Almost invariably the number of breaths has decreased, usually by 20% to 50%. This gives immediate feedback that the body has changed with this type of breathing and how this likely also reflects a decrease in the fight-flight response.

After teaching the importance of decreasing stress, we go on to discuss triggering the body’s calming (or relaxation) response. We talk about the difference between decreasing stress (decreasing adrenaline) versus triggering the body’s calming response (stimulating endorphins). This sets the stage for further education about relaxation techniques and how all relaxation techniques trigger this endorphin response. In some groups, we teach a specific relaxation technique (body scan or modified tai chi); in others we ask patients to explore and chose their own relaxation technique—one that best fits their personal philosophy. We believe that there is not one “right” or “best” relaxation technique, but it is an important skill and all pain patients should be familiar with some sort of calming technique to use as needed, if not regularly.

Last updated on: May 30, 2014