A Self Help Guide

This booklet discusses a number of techniques that can help you to manage your pain more effectively. By using these techniques and making them part of your daily routine, we hope you will be able to manage your pain better, making life more enjoyable and rewarding.

Section 1: Understanding your pain

What is chronic pain?

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Chronic pain is pain that has lasted for longer than 3 months after the usual recovery period for an illness or injury. It may be as a result of a chronic condition. It may start with a definite problem at a certain time or come on gradually, perhaps for no obvious reason. It may even come on some time after an event; where you have managed an activity at the time but you feel pain afterwards. Chronic pain can be felt in a specific part of the body, e.g. back, shoulder, legs, or more generalised, throughout the body. The pain may be continuous or occasional, you may feel more sensitive to pain and it may sometimes be prone to flaring up or getting worse very quickly.

Despite treatment attempts with medication, rest and relaxation, hot baths or massage, this chronic pain may not be effectively relieved. Things that would usually settle or treat our pain are not successful for chronic pain. This is because the problem is with the pain system, rather than being located in any specific part of the body. The pain system does not appear to be functioning normally or as you might usually expect.

There is still a lot that is not understood about chronic pain and the pain system. For example, why the pain continues on after things have healed or why pain can be present without any physical problem being found. For example, if a prolapsed disc is taken out, you would expect the pain to go away after the surgery. But in some cases the pain does not change, and the patient experiences just as much pain as they had done before the operation.

Living with chronic pain can be stressful. Managing at home, work, with friends and family as well as many other things can be difficult. You may not feel you have any control over the pain and don’t feel able to cope with it.

Experiencing pain can lead to feelings of anxiety or fear about what might be causing the pain; especially where there is no obvious cause. It may feel like damage is being done to your body and you may feel some concern about what the pain might mean – what damage could have been done and what the future might hold.

Feeling pain can also make you feel tense, especially if you expect the pain to come back or get worse. You may feel easily angered and hostile towards people who you meet that don’t understand your situation or how your pain affects you. Some people even feel anger towards the pain itself.

When things aren’t going so well it can lead to feeling bad tempered, anxious, frustrated and having troubling thoughts. You may feel hopeless and very down about feeling this pain, which can result in depression.

The pain itself or worrying about it may cause difficulties with sleeping. You may be kept awake or find it difficult to stay relaxed. Being tired and having a sleepless night can make people feel more upset and bad tempered.

How do your feelings and thoughts affect your pain?

Our experience of pain always stays with us; we have a kind of memory for it. For example, if a person come across pain every time we carry out an activity or task, then it is unlikely that they will continue with it, or for that matter, ever return to it. The more often we associate something with pain, the more we are likely to actively avoid it.

Thinking of the pain before it happens can make it feel worse. A feeling of pain may even be set-off just by thinking of a past experience of pain. <p'>Depending on the situation, a person’s threshold for feeling pain may be altered. Sometimes what would feel a little painful may be excruciating and vice versa. For example, during a rugby match a player may be injured but not feel significant pain until after the match. This is caused by a hormone called adrenalin, which prepares our body for action in circumstances which are perceived as risky. Similarly, during an activity which we enjoy and makes us feel good, any pain is often dulled by similar chemicals called endorphins; there is often less of a focus on any pain experience. However, on the other hand, a person who is feeling very anxious, tense and wound-up in another circumstance may not be able to tolerate even the slightest touch. In these scenarios how a person feels has affected their perception of the pain – a person’s thoughts and mood can make a difference to how they feel pain.

Activity levels

People with chronic pain cope with it in different ways. Below are three examples of how different people have tried to deal with their pain.

Example 1. Some people stay active until they can do no more and then rest to recover before returning to an activity for as long as they can again. This may result in their pain getting worse or flaring up as they carry out an activity for too long. The time taken to rest may steadily increase.

Example 2. Some people manage very little and stop an activity at the slightest hint of pain in order to avoid over activity and ‘making things worse’. If such people begin to feel pain earlier and earlier in the activity this may stop them from participating at all.

Managing your activity

It is better to take a balanced approach to your activities, so you don’t burn-out or become completely inactive. You need to take an active interest and involvement in the management of your pain; breaking the vicious circle of feeling worse and doing less.

Some people may feel pain almost all the time; it is there in the background. When it gets worse and flares up, they find it difficult to cope. It is important that you spot the things that are making it worse and find ways to make this happen less often. Learning what to do when your pain is worse will also help, so that it does not add to the problem and end up making things worse.

• Plan how you intend to start an activity and how long you will do it for. Just as an athlete in training you can then gradually build this up to a level which you are happy with. This pacing of your exercises helps you to introduce things in a controlled and responsible manner.
• Set yourself positive goals which are realistic, specific and measurable you will begin to see how you are progressing.
• Prioritise your activities so that you are achieving things in the order that you would like to. Also if you are finding things difficult then you can have finished the tasks most important to you.
• Exercise whenever possible, this will not only keep you fit and take your mind of things, but may also help you feel better.

Section 2: Managing your pain

1. Pacing & Spacing activities

Pacing is a technique that you can use to gradually increase your level of activity.

If you have chronic pain, you might find that you have good days, when you can get on with things around the house or do something that you enjoy, and bad days, when you can do very little. As time goes on, some people find that they have fewer good days and more bad days. Pacing is all about breaking this pattern and gradually increasing what you can do. It should be possible to pace any activity, although in everyday life, we are not used to doing things gradually - we like to get things done quickly. But pacing really does work!

Pacing really does work; you can stay motivated by continually achieving a series of small goals!

Spacing involves breaking down an activity into manageable chunks and taking some time out between each chunk to rest and relax. By dividing up tasks in this way you can keep an eye on how you feel and how you are getting on with the task.

2. Goal setting

Chronic pain can affect lots of different aspects of your life. You may find that you have had to give up going places or doing things that you used to enjoy because you are afraid that this may make you feel worse. Also, it may be a little frightening to think about starting something new.

Goal setting is rather like pacing - you can use it to gradually build up the activities that you do. It's all about giving you some control back, rather than letting the pain take over.

A goal is something that you would like to achieve. It may be going to the cinema, walking the dog, or playing with your children or grandchildren. You could have all kinds of different goals, and they can be either short- or long-term.

There are four golden rules for setting goals:

	The goal must be realistic.
	It must be something you can measure.
	It should be your own goal - don't let someone else pick it for you.
	Don't be too ambitious to start with – pick something that's important to you, but not impossible. Look beyond your pain to what's important in your life.

	Getting in and out of the car
	Sitting in the driver's seat
	Turning your head to look in the mirror
	Twisting to put on your seat belt
	Moving the pedals up and down
	Leaning forward over the steering wheel
	Pulling the handbrake on
	Changing gear
	Opening and closing the door
	Concentrating on the road
	Looking to the side as you pull out of a junction

Now look at each of these things in turn - what do you have problems with? If, for example, you have a problem with sitting, you should start by gradually increasing the amount of time that you sit in the driver's seat. Use the pacing technique described on Page 8 to do this. To start with, you might only be able to sit for a minute or two, but after a few weeks, you should hopefully be able to build this up to 15 minutes or so. You may also want to make practical changes, such as back supports and wider mirrors.

It's important to review your progress regularly - about once a week if you can - and re-think some of your methods if they're not working. Always remember that each small step is an achievement in itself, and that lots of small steps can help you take one big leap. Hopefully you'll be on your way back to a more active life.

Remember – always take time to enjoy your successes.

3. Assertiveness / Communication

People with chronic pain sometimes lose their confidence, finding it hard to express their needs. If you don't express your needs clearly, this can increase your tension, which as you know, can increase your pain. So it's important to communicate well and to be assertive. You can do this by following the simple tips given below.

	Be firm and say what you mean
	Try not to complain, plead or be apologetic
	Don't shout or raise your voice, keep it calm and low
	Make sure your message is clear, rather than expecting people to guess what you're getting at
	Don't tell people what to do, but explain to them why you're asking them to do something
	Ask for help when you need it
	When you're asking for something, say 'I want' instead of 'I need' and 'I don't want' instead of 'I cannot'
	Be precise and to the point - don't beat about the bush!

It’s ok to change your mind and to say ‘no’ without feeling guilty - you’re in control.

4. Stress

Stress and tension can make your pain worse, so it's important that you learn how to cope with (or even avoid) stress. This involves knowing what it is and recognising when you are suffering from it.

When undertaking activities you must be sensitive to the feelings that you are having, especially in relation to any pain that you may experience. Being aware of your emotions and taking action to calm yourself down and relax despite the pain will require practice and patience.

In our day-to-day lives, each of us faces physical and emotional demands from our friends, family, work and so on. Most of the time, we can cope with these demands and there's no problem. However, stress occurs when you find that you are unable to cope. As well as increasing the pain, this can make you quick-tempered, weepy, angry and frustrated. Chronic pain itself also causes stress.

	Being able to relax.
	Having someone to talk to and confide in.
	Being able to find a practical solution to the problem, rather than worrying about it.
	Using pacing techniques and breathing exercises.

5. Sleep

Those with chronic pain often find that they have problems sleeping. You might find it difficult to get off to sleep, or find that you wake up during the night because of your pain. Unfortunately, the more you try to sleep, the harder it sometimes becomes. This can increase your stress levels, which can make the pain worse, which, in turn, makes it more difficult to sleep. So, it's like a vicious circle. If this sounds familiar, try following the advice below:

	Try not to nap during the day, no matter how tired you feel - do something else instead
	Avoid tea, coffee, alcohol and cigarettes for 4 hours before you go to bed
	Wait until you feel tired before you go to bed
	Be aware of the messages you give yourself about bedtime - don't go to bed expecting not to sleep!
	Try to go to bed at the same time each night
	Do not read, eat or watch TV in bed
	Make sure that your bed is comfortable - use pillows to support your legs and back
	Use relaxation and breathing exercises in bed
	If you can't get off to sleep, get up and do something, such as reading or relaxation exercises
	Get up at the same time every morning, regardless of how much you slept during the night - set your alarm clock if you need to

Remember – a good short sleep is better than tossing and turning all night.

6. Exercise

If you have chronic pain, you may be afraid to do exercise, but staying active, within realistic limits, can be very beneficial.

When a person experiences acute pain, it makes them rest so that healing can take place. For example, if you sprained your wrist, the pain would stop you using it so that it can heal. However, with chronic pain, you may feel pain even if there is no injury and no healing. This pain causes you to avoid certain movements and activities, making your muscles and joints stiff. This, in turn, makes the pain worse - this is called the pain cycle.

Remember, unused muscles feel more pain than toned, flexible ones. Find an exercise plan that is suitable for you, and as you build up your strength, you will be able to do more exercise.

7. Coping with flare-ups

From time to time, you may find that you experience periods of increased pain, sometimes called flare-ups. Although these flare-ups don't usually last very long, they often come on quickly and without much warning, so they can be difficult to cope with. It may be tempting to go back to your old habits, like taking more medication or going to bed. Try not to do this. Flare ups may happen, and if they do then all we can do is accept that. Coping with flare-ups is a skill and will grow with time and experience. You might also find that preparing in advance for any flare-ups can really reduce your distress.

	Recognise what is happening
	Don't panic
	Take your medications regularly
	If you are unable to continue with your exercises for a couple of days, start slowly and re-set your goals if you need to
	Try to think positively - negative thoughts can make things worse
	Be kind to yourself!
	If the flare-up carries on for more than a few days, contact your nurse or GP

8. Relaxation

Learning relaxation techniques can be a very useful skill to help cope with and manage pain. Anxiety, tension and stress can make the pain worse. Also, the pain itself can lead to anxiety, tension and stress, so it's like a vicious circle. The trick is to break this cycle and relaxation can help you to do this.

It sounds easy, but learning to relax takes time. You have to practice everyday. Don't be too ambitious when you first start – also, it's best not to try the techniques if you're having a really bad day, as they probably won't work. However, as you get better at relaxing, you will be able to use the techniques when you are having a bad day, and you will even be able to practise when you're out and about, standing in a queue, sitting in the car, etc. You might find it useful to keep a relaxation diary - make a note of the type of relaxation exercise you did, when and where you did it, and how it felt. This diary should help you to see an improvement in your relaxation skills.

Use this quick, simple relaxation exercise whenever you feel tense. You can use it anytime, any place - when you're sitting down or even in crowded places.

• Take one good, deep breath
• Keep breathing slowly and deeply
• Let your shoulders droop
• Relax your hands

Deep Relaxation

1. Get prepared.
   Find somewhere quiet. You might like to play some soothing music. Sit in a comfortable chair or lie down (on your front, back or side). Make yourself comfortable, e.g. you might want to bend your knees. Close your eyes and breathe deeply. Relax your body - let it go all loose and floppy

    

2. Relax your muscles.
   As you breathe in and out, relax all the major muscle groups in turn Start with your feet. Is there any tension? If there is, release it and relax - and at the same time, say 'my feet feel calm and relaxed'. Do this three times, then move up to your calves, bottom, and so on.

    

   
3. Calm your thoughts.
   Stay fully relaxed, and breathe slowly and regularly. Distract your mind by thinking about a relaxing, pleasant scene or playing some soothing music.

    

For example, imagine that you are in the countryside on a sunny summer afternoon. Imagine that you are slowly walking on your own through a field … you can feel the warmth of the sun streaming down from the blue sky. You can see the grass, the trees and the flowers in the field. You can hear the birds singing, and in the distance you can hear children's voices. Feel the ground beneath you as you walk, and walk slowly, looking at everything around you. Think about what you can see, hear, smell and touch. Focus all your thoughts on this scene, and remove any other thoughts or worries that may come to mind.

4. Spend five minutes fully relaxed physically and mentally.
   When you want to get up, count backwards from four to one. You will hopefully feel refreshed, wide awake and calm. Keep this feeling with you when you carry on with your daily routine, and don't rush around too fast. Stay as calm as possible.

   You can practise any of the exercises described above on your own, but why not consider joining a yoga or gentle movement group? For example, Dru Yoga is particularly suitable for people with pain or disabilities.

    

9. Breathing

The way that you breathe is very important when you are in pain. This may sound strange, as breathing is something we don't usually think about! However, when you are in pain, your breathing may be shallow or you may find that you are holding your breath. This can lead to tension, which may make your pain worse. The trick is to take time to think about your breathing, making sure it is slow and relaxed.

The exercise described below can help you do this. Your diaphragm is a band of muscle that sits just below your lungs. It helps you to breathe by moving up and down, forcing air in and out of the lungs. Normally, this happens spontaneously, you don't have to think about it. However, there is a technique called 'diaphragmatic breathing', in which you deliberately use your diaphragm to control your breathing.

	Start off by making sure that you are comfortable
	Make sure that your back is well supported and put one hand on your upper chest and the other on your tummy
	Now close your eyes and focus on your breathing
	Notice how quickly you are breathing and try to slow it down
	Take a long, slow, relaxed breath in through your nose. Push out your tummy (this helps your lungs to fill up) and feel the air gliding slowly down in to your lungs
	Hold it there for a few seconds, then slowly breathe out again through your mouth, with your lips slightly parted. Let your tummy fall - this helps get rid of the air from your lungs
	Take another long, slow breath in, pushing your tummy out, then breathe out, letting your tummy fall
	Think about your neck and shoulders - is there any tension there? If there is, bring your shoulders up towards your ears, then slowly lower them back down, loosening any tension
	Check for signs of tension in any other parts of your body
	Focus on your breathing again, taking slow, relaxed breaths in through your nose and slow, relaxed breaths out through your mouth. Imagine the tension flowing away with every breath out

Summary

There are various things that you can do to help keep on top of your pain. Although we cannot promise to reduce the pain, this guide can introduce you to ways that help it have less effect on the quality of your life and help you feel more in control. By learning ways to cope with chronic pain and understanding more about it, hopefully you can manage better to live with your pain.

Where can I get further help?

We hope you will find this guide helpful. In order to get the maximum benefit, it is best to continue the exercises described here over a period of several weeks, as problems usually take some time to overcome. These approaches are tried and tested and most people find them beneficial if they persist. You are learning new, healthy habits which will stand you in good stead for the future. It is a good idea to keep this guide handy so that you can keep referring to it from time to time.

If you feel so distressed that you have thoughts of harming yourself or you feel you are at risk of harming others, then visit your doctor as soon as possible and explain to him or her how you are feeling.

Further Information and Resources

For further information and self-help resources go to Moodjuice online:

http://www.moodjuice.scot.nhs.uk

Moodjuice Forth Valley is a web site designed to offer information and advice to those experiencing troublesome thoughts, feelings and actions. From the site you are able to print off other self-help guides covering conditions such as depression, anxiety, stress, panic and sleep problems. In the site you can explore various aspects of you life that may be causing you some distress and obtain information on organisations, services and other self-help materials, that can offer you support and information which will allow you to help yourself.