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Tackling Chronic Pain

The Multi-Modal Strategy of Functional Restoration

By Spondylitis Association of America

Tackling Chronic Pain
This article originally appeared in the Winter 2015 issue of Spondylitis Plus, the quarterly news magazine of Spondylitis Association of America. Members receive every copy of Spondylitis Plus in the mail for free.

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We wrote about chronic pain and central sensitization in the Fall 2015 issue of Spondylitis Plus. In this piece we are digging deeper and exploring chronic pain treatment options in further detail. If your spondyloarthritis is being appropriately managed, but you are still living with uncontrolled pain, additional therapies may be needed. While there are numerous options and modalities available, and pain medications can make a notable difference for some, in this article we will discuss functional restoration as it applies to pain management, and focus on active interventions.

We thank the American Chronic Pain Association for allowing us to adapt and print excerpts from their comprehensive Resource Guide to Chronic Pain Medication and Treatment. The guide is an extensive consensus document, researched, written, and kept up to date by physicians specializing in pain management. You will find a link to the extensive document at the end of this piece.

We begin with an introduction to Functional Restoration:

Functional restoration can be defined as the process by which an individual acquires the skills, knowledge, and behavioral changes necessary to assume or re-assume primary responsibility for his/her physical and emotional well-being. Functional restoration thereby empowers the individual to achieve maximum functional independence, to have the capacity to regain or maximize activities of daily living, and [when possible] to return to vocational and avocational activities.1

But, what about THE PAIN? Can’t the right pain medication or procedure just take it all away and return us to full function? Not according to this model; medications or other passive modalities are only one part of the chronic pain solution. According to this model what is often missing here is active intervention.

It helps to think of a person with chronic pain as like a car with four flat tires. Our expectation is that all we need is that one medication or treatment that will take away the pain. But [medication] only puts air in one of our tires; we still have three flat tires and can't move forward. Perhaps the medication or treatment has provided 25 or 30 percent relief. Let's leave that there and ask what else we need to fill our other three tires.

For each person the necessary combination of therapies and interventions will be different, based on individual need. Unlike traditional medicine where the "patient" is a passive participant, living a full life with pain requires that we take an active role in the recovery process. We need to work with our health care providers to find what we need to fill up our other three tires.2

So what exactly is meant by Active Intervention? Active interventions are treatment modalities that require the active participation of the individual.

Active intervention modalities include education, exercise, functional training, and psychological and behavioral approaches.

Education

Education regarding chronic pain should start as soon as the pain has been identified as chronic. Early topics should include helping a person understand that they may not be "fixed" but instead their pain must be managed. It can be helpful to think of chronic pain similar to other chronic diseases such as diabetes. A person needs to manage their diabetes and prevent it from getting worse and causing other problems. Diabetes is not quickly cured or fixed. The same is true for chronic pain. Further education on chronic pain should also include understanding that pain is not "all in your head" but that an active approach that focuses on the whole person is the most effective way to treat chronic pain. What someone can and cannot do should be defined as clearly as possible.3

Exercise (Active Therapy)

The overwhelming theme in the treatment of most persons with chronic pain is to keep as physically active as possible. In fact, one of the best treatments for chronic low back pain is exercise. After consultation with a health care professional and/or physical therapist, a therapeutic exercise program should be initiated at the start of any chronic pain treatment program.

Therapeutic exercise can be classified to include:

  1. range-of-motion exercises
  2. stretching
  3. strength training
  4. cardiovascular conditioning.

Active therapy is based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, and range of motion, and can alleviate discomfort.

Persons with chronic pain can become discouraged when their pain temporarily increases due to therapeutic exercise, and they will sometimes terminate treatment too early before achieving maximal benefit. A flare-up of pain with exercise should be expected even with safe exercise, but can also be due to poor body mechanics, guarded or stiff movement, high levels of demand on an injured site, or compensatory movements. It is important to have a health care professional knowledgeable about treating chronic pain to assist not only with setting up a graded and careful exercise program, but also to assist with distinguishing new symptoms that may signify problems from the "good" discomfort that normally goes along with an increasing exercise program.4

Functional Training

Functional activity training is just as important as performing a daily exercise program. Lifting, carrying, pushing, pulling, reaching, bending, digital dexterity, and handling are all examples of functional movements that are used on a daily basis. It is helpful to think of practicing daily activities similar to performing exercises. It is important to first determine the current ability to perform tasks. Each task is then practiced with appropriate pacing of activity, flare management and slow progression.5

Some exercise forms can also double up as functional training opportunities and deliver exceptional results for some. These include tai chi, yoga, and Qi Gong.

Psychological & Behavioral Approaches

The definition of pain is "…a negative sensory and emotional experience." (International Association for the Study of Pain). This definition recognizes that along with pain comes an emotional response and reaction. People naturally respond to pain by wanting to escape it. With chronic pain, one cannot easily escape pain that is coming from inside the body. Sometimes people try to escape pain by retreating to the bed or becoming sedentary. While these strategies (known as fear avoidance) seem like a good idea on the surface, sedentarism is actually know to worsen pain over time and it leads to deconditioning and contributes to depression. A pain psychologist helps people to learn techniques and skills to calm the distress that naturally arises during pain, and this alone can help reduce pain. Research shows that psychological distress about pain actually amplifies one’s experience of pain.

A therapist can help to break this cycle by exploring ways for the individual to gradually improve function, reduce worried thoughts, and improve mood. Strategies that have been most helpful include monitoring daily activity and mood, using problem-solving techniques, challenging some of the recurrent worried thoughts, engaging in a gradual exercise program, watching body cues, maintaining a daily routine and schedule, learning to pace activities, watching diet and caloric intake, getting involved in distracting activities with others, sharing emotions associated with the pain, and contacting others for help when needed.

Therapists trained in behavioral medicine also often teach relaxation training using various mind-body interventions and techniques that include diaphragmatic breathing, progressive muscle relaxation, autogenic relaxation, guided imagery, cue-controlled relaxation, and hypnosis.

It is important to remember that the goal of psychotherapy and behavioral therapy is not to ‘cure’ or get rid of the pain and seeing a psychologist or other counselor does not mean that the pain is not real. Psychotherapy can help individuals better manage their pain to lessen its impact on activities, relationships, and other aspects of their daily lives.6

Going back to the analogy of the car with four flat tires, it becomes clear why current research and best practices in pain management are increasingly recommending the holistic approach for treating chronic pain. Functional restoration is a treatment model that asks a great deal of the person living with chronic pain, but also offers a better outcome than any one intervention has thus far.

Excerpts reprinted by permission of ACPA, 2015.

1. Feinberg, Steven, et al. "Resource Guide to Chronic Pain Medication & Treatment." 130.
2. Feinberg, Steven, et al. "Resource Guide to Chronic Pain Medication & Treatment." 9.
3. Feinberg, Steven, et al. "Resource Guide to Chronic Pain Medication & Treatment." 118.
4. Feinberg, Steven, et al. "Resource Guide to Chronic Pain Medication & Treatment." 119.
5. Feinberg, Steven, et al. "Resource Guide to Chronic Pain Medication & Treatment." 120.
6. Feinberg, Steven, et al. "Resource Guide to Chronic Pain Medication & Treatment." 124-128.

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