PAIN MANAGEMENT GROUP

1. PAIN MANAGEMENT GROUP

2. PROGRAM DESCRIPTION • The objective of this pain management program is to help you understand what chronic pain is, why certain treatments have been prescribed, and help you explore/develop “new” skills for coping with pain so you can enjoy a fuller life.

3. Goals Of The Program 1. Understand the pain process 2. Recognize what factors increase or decrease pain 3. Understand proper use of medication and their side effects 4. Enhancement of physical functioning 5. Learn how to improve your sleep, mood and relationships 6. Reduction of pain intensity

4. Theory of Pain • What is pain? • it’s a symptom • it’s a complex process that involves biological, psychological, behavioral, cognitive, spiritual and cultural issues. • the perception of pain can be magnified, colored, and reinterpreted by people’s experiences and expectations.

5. Acute Vs Chronic Pain Acute Pain • has an identifiable source, new damage or injury • it is time-limited • improves with rest and time • use of narcotics is normal Chronic Pain • unrelieved pain and the symptom itself becomes a disease • it lasts longer than 3 months • activity is necessary for recovery • control of medication, to prevent overuse is a must

6. How To Take Control Of Your Pain • Acknowledge that you are in pain • Feeling sad, anxious, angry, & depressed is normal • Recognize that you do have choices • Determine exactly what is going on, communicate effectively about your pain • Set realistic desirable goals • Recognize that you can learn to distract yourself consciously from pain

7. The Process Involved In Acute And Chronic Pain The role of the Peripheral Nerves in pain • Pain sensory nerves serve as a warning system responding to damaging extreme, trauma, or chemical messengers that are released during inflammation. • Sensory nerves bring information about sensory sensations to the spinal cord • Sensory nerves hand over these messages to other nerve cells in the spinal cord where the message may be added to other sensory messages received, dampened down, or carried all the way to the brain. • Different sensory fibers carry pain sensation at different speed, as a result of that pain is experienced differently

8. The Spinal Cord’s Role In Pain • Once a pain message makes it to the spinal cord as an electrical impulse, there is a “gate” which determines whether the message will be send, changed or go through. Known as • The Gate Control Theory helps explain how you may not notice how much you are really hurting when you are distracted by something else, but are definitely aware of your pain when you are alone, or not distracted by another activity at the time.

9. Pathways from the brain down through the spinal cord, influence how pain is interpreted. • Pain from the sight of injury, travels to the brain with great speed; this is then interpreted by the brain which makes you aware of your pain and discomfort. At the same time the messages that go to your brain are also influenced by messages coming down from your brain.

10. What Happens In Chronic Pain 1. This involves processes that take place in the peripheraltissues, such as muscles spasm, nerve irritation, inflammation, and in the nervous system. 2. In chronic pain what appears to have happened is that during regeneration of a nerve that has been injured, spontaneous pain messages will be sent to the spinal cord; this “injured nerve” then fails in conducting its normal checks and balances of “normal pain” nerves, and continues to fire even though no injury is occurring.

11. 3. This results in the spinal cord being bombarded by persistent intense levels of pain signals, which results to changes in various areas of the spinal cord. Thus, these areas that are responsible for regulating pain in the spinal cord, eventually lose their ability to respond to the normal checks and balances which serves to modulate or dampen pain, and act independently to perpetuate the pain signal

12. Factors Influencing Pain • Physical factors • Drugs • Stimulation; reduced muscle tension or arousal • surgery • Emotional factors • Relaxation and stress reduction • Positive outlook and pursuing activities of interest • Emotional stability • Mental Factors • Positive attitude • Feeling of control • Ability to redirect attention

13. The Role of The Brain In Pain • The brain responds to the strength, repetitiveness and duration of the pain message, whether it comes from normal or abnormal pain nerves. • The brain can change the pain message by firing impulses that make their way through the pain inhibitory system or through the release of endorphins and other “morphine-like” substances.

14. The brain gives meaning to the pain message, through connections with the cerebral cortex and limbic system, which allows the pain message to become a conscious and emotional experience • Certain conditions that affect optimum brain functioning are: • Insomnia • Depression/Anxiety • Use of narcotics/sedatives/alcohol

15. Treating Abnormal Nerve Activity • Various medications may be used to change abnormal pain nerve activity i.e. TCA’s, Mexiletine, Novocain, Baclofen, Dilantin, Clonopin, etc. Nerve blocks with Novocain-like substances and steroids may be prescribed to alter the firing of abnormal nerves • Not all pain messages are paid attention to , there is competition among the messages coming into the spinal cord • Rubbing, applying pressure, or changing stimulation to a painful area can be helpful in alleviating pain from time to time.

16. Therefore, it is important to: • listen to your body • pace yourself • set realistic goals • use your body to change your mind/use your mind to change your body.

17. Treatments for Chronic Pain • Medications • Relaxation Training • Exercise • Stress management/problem solving • Acupressure • Acupuncture • Massage

18. GSR2 • The GSR2 is a portable biofeedback system. This allows you to detect and amplify internal body activities that may be too subtle for normal awareness. • One of the main ways that the body reacts to tension and stress is through your skin. The GSR is merely a reflection of variations in your sweat gland activity and pore size, both of which are controlled by the sympathetic nervous system. • Skin resistance increases when you are clam and relaxed and the vice versa when you are tensed.

19. The GSR2 helps you develop the ability to control tension and stress, by giving you an auditory signal in response to your level of tension/relaxation. That is as you learn to relax your resistance increases and the tone of the GSR2 decreases, as you tense your skin resistance decreases and the tone becomes louder.

20. Let’s Explore How Pain Has Affected Your Life • How has pain affected your work, play and ability to perform your daily activities? • What other symptoms do you experience in addition to the pain? • What are your thoughts and feelings in response to your pain experience? • What does being in pain mean to you?

21. Goal Setting • A goal should be measurable • A goal should be observable/behavioral • A goal should be realistic • A goal should be desirable • A goal should focus on things I can control • Steps required to attain a goal need to be clearly outlined

22. MIND-BODY CONNECTION • Mind and body are interconnected. This can be clearly demonstrated with the experience of stress. The mind perceives something as posing physical or psychological danger and in turn we experience physical and emotional reactions. • “Fight-or-Flight” – is the body’s automatic response to danger. During such times the SNS releases adrenalin, and the PNS secretes ACH.

23. The changes in your body that constitute the fight or flight response: • Increased heart rate • Increased breath rate • Increased blood pressure • Changing of blood flow to muscles

24. Mind Modulation of Cell Activity • Whenever a particular situation occurs the mind generates thoughts and imagery in the frontal cortex. • These thoughts-imageries are filtered through the memory of past experiences and emotional areas of the limbic-hypothalamic system and changed into the neurotransmitters that regulate the organs of the Autonomic Nervous System, which branches in the Sympathetic and Parasympathetic Nervous System.

25. These neurotransmitters initiate the third stage in the process of information change from the thoughts, images and emotions of mind to the biochemical responses within the individual cells of the tissues and organs of the body. • This path of information transduction is being modulated constantly and automatically on an involuntary, unconscious level by the state-dependent encoding of memory, learning and behavior from our daily life experiences.

26. Mind Modulation Of The Endocrine System • Information is processed in the frontal cortex, and then filtered through the individual’s repertory of experiential life learning that’s encoded in the limbic-hypothalamic system • The transduction of the this learning by the hypothalamus into the releasing factors that control/regulate the endocrine’s pituitary gland that in turn release a host of hormones which regulate the entire endocrine system of the body.

27. Mind Modulation of the Immune System • There is clear evidence of how psychological stress can affect the expression of IL-2 receptor gene expression and IL-2 messenger RNA in white blood cells • Inhibiting or stimulating the hypothalamus results in changes in immunologic reactivity, also activation of an immune response in the body results in changes within the hypothalamus

28. Mind Modulation of the Neuropeptide System • The limbic-hypothalamic locus of neuropeptide activity is enriched with opiate receptors, substance P, bombesin, CCK, neurosensin, insulin and transferin. • The brain stem and spinal cord include the modulation of sensory information. The dorsal horn were neurons transmit information from glands, skin, and other peripheral organs make their first synaptic contact with the CNS, here the neuroreceptors filter incoming sensory information so that the whole organisms perception of a particular event is compatible with survival.

29. Effects Of Chronic Stress Chronic Pain • Chronic stress or chronic pain causes the body to overextend itself in order to maintain balance, eventually it wears itself out, its recuperative abilities get exhausted. Symptoms like fatigue, headaches, poor concentration, SOB, weight loss/gain, increased muscle tension, anxiety/depression , sleep disturbance, GI problems, and reduced immunity.

30. The Relaxation Response (RR) • It is voluntary • It can be achieved by focusing one’s mind or a repetitive phrase, breath or action • Adopting a passive attitude toward the thoughts that go through one’s head

31. The Physical Effects of RR • Immediate changes which occur while a person is focusing on a repetitive word; lowering of blood pressure, heart rate, breath rate and oxygen consumption. • Long-term changes, which take place after repeated practice for at least a month; alter the body’s response to adrenalin.

32. RR Techniques • Using a focus word or phrase • Coupling breathing with imagination • Progressive muscle relaxation • Using repetitive motion • Creating a safe place • Using hypnosis • Using visualization

33. Using Breath To Relax and Focus Your Mind • Chest Breathing • Diaphragmatic Breathing • Sit in a chair and clasp your hands behind your head; point your elbows out to the side • Place your hands just below your belly button; close your eyes and imagine a baloon inside your abdomen; • Breath focusing exercises

34. Mind-Body Connection • Let’s see how the body can affect the mind. This can be achieved by: • Pacing Yourself- engaging in an activity routine consisting of regular “uptime” and “downtime” periods will enable pain patients to increase their activity levels and decrease their pain over time.

35. Listening to your Body- • Gently stretch your muscles • Gently move your limbs through their range of motion • Isolate muscle tension • Relabel sensations • Use breathing to release tension • Develop body awareness

36. Let’s Explore Other Ways Your Body Affects Your Mind • Push yourself by using denial of your condition • Withdraw from any type of activities • Ignore any sensations from your neck down • You rationalize painful sensations

37. Pacing Yourself • Alternate between more and less physically strenuous • activities. • Establish your pain baseline • Go up to no more than 1-2 points above your baseline, then • switch to a lower level of activity • Once you establish your “uptime and downtime” then you are • ready to pace yourself. So whenever you know you are going to • engage in a strenuous task time yourself. • As you do this consistently you will find that the “uptime” • lengthen and “downtime” will shorten.

38. Common Problems With Pacing • Difficulty deciding what you can and cannot do • Feeling guilty for not doing something and taking time for yourself • Experiencing delay in pain increases, as a result of “deconditioning”-combination of decreased muscle strength and endurance due to lack of exercise. • Don’t forget to remember that pain level does not necessarily correlate to your ability to function

39. Time Management • How much time do you devote for your needs? • Do I need to be involved in all of the activities that I am, or am I • having a hard time to letting go? • What activities can I share or assign to someone else? • What activities that I am not currently pursuing would I like to add? • How much time do I have of high-quality recuperative time?

40. Listening to Your Body • Labeling sensations in your: • Legs • Arms • Stomach/chest • Shoulders • Head/face

41. Rating Your Pain • Learning to translate physical sensations into numbers. • Use scale of 1-10. • Procedure: • Make a fist, tighten it to a rating of 5; then make a fist tighten to a rating of 2; notice the difference • Relax the fist, wiggle your fingers; • Make a fist with a rating of 9; notice the difference • Relax your fist

42. Using Your Body to Change Your Mood • Posture and facial expression, they do change your mood!! • Raise your eyebrows • Show your teeth • Keep it for 30 seconds!

43. Thoughts, Feelings & Sensations “Do not wait for events to unfold as you wish them to unfold. Decide to want what occurs……and you will be happy.” Epictetus, 1st century B.C.

44. Environment Thoughts Sensations Feelings Behavior

45. Pain and Depression • Depression- feeling sad, having trouble sleeping, loss of interest in various activities are common symptoms that can be indicative of the struggle one has to cope with pain, and the way pain interferes with your daily functioning. • Depressed people can complain of somatic problems, which subside when the depression is treated. In chronic pain patients with the treatment of depression, the pain does not go away but rather the pain experience changes.

46. Pain and Anxiety • Anxiety- feeling worried/fearful as a result of one’s perception of being in danger, threatened or vulnerable in some way. • Negative feelings that arise as a result of anticipating that something “bad” will happen. • Feelings that arise when one underestimates their ability to cope.

47. Mind Over Mood 1. Identify thoughts and situations associated with depression and or anxiety • Situation: who, what, when, where • Mood: rate your mood • Automatic Thoughts

48. Look for evidence that supports the automatic thought • Look for evidence that does not support the automatic thought • Alternative Balanced Thoughts- combine 2 and 3. • Rate your mood again.

49. Identifying Core Beliefs • Core beliefs about SELF • Core beliefs about OTHERS • Core beliefs about the WORLD • Identify the situation • What does this mean about me? • What does this means about others? • What does this mean about the world?

50. Pain, Guilt and Anger • Anger arises when we feel we have been treated unfairly, important rules and beliefs were ignored/violated, hurt unnecessarily, or prevented from getting something we expected to achieve. • Guilt arises when we feel we have violated basic beliefs or rules, blame ourselves for a particular situation.