Making the most of a referral for pain management

As part of a medical review, a doctor may recommended a person attend pain management – what does this mean and how do you make the most of it?

Pain management usually refers to using a cognitive behavioural approach to self managing pain.  Rather than directly trying to reduce pain or treat any underlying injury or ‘tissue problem’, the focus shifts to what the person can do to manage his or her health and life goals.  Self management of pain includes understanding the factors that influence the experience of pain, setting goals, problem solving, and moving from being a patient to being a person. 

Usually people set functional goals, develop an exercise programme to help them achieve these goals, while at the same time learning to review how their thoughts and beliefs affect their ability to maintain positive changes.  Pain management programmes may be delivered within a group setting, or individually; they may be provided by a range of health professionals – but usually include a physiotherapist, clinical or health psychologist, occupational therapist and medical practitioner.  They can range in length from three or four weeks intensive full-day programmes to lower-intensity, two or three days a week programmes of up to 12 weeks. 

There are some things to clarify about what pain management will not do!
Pain management will not:

• Remove or ‘cure’ the pain
• Immediately increase a person’s function
• Directly address return to work issues
• Be successful if the person is looking for a cure or wants a health professional to manage their pain problem

Pain management works best when:

• Everyone involved in the person’s health care team agree that managing pain is now the focus, rather than trying to ‘fix’ or cure the problem
• It is provided within an interdisciplinary team
• It is started early in the rehabilitation process
• It directly addresses how the person will use active coping strategies in everyday situations such as work

There is not a lot of agreement in the research about the exact components that need to go into a pain management programme.  At the moment, the evidence shows that at the end of a pain management programme – and for long periods afterwards (years even) – people are able to do more, feel more positive, in control, and are less distressed.  The key change seems to be about the attitude towards pain rather than any particular ‘technique’ – and some research shows that many people don’t end up using the coping strategies they might have learned during a pain management programme at all after about a year!

Pain management in many ways is like attending a drug rehabilitation programme.  Unless the person is ready for this step, it won’t be helpful.  People need to be ready to (a) accept that their pain is likely to remain, (b) that a cure is not ‘just around the corner and (c) they need to take control of their lives rather than ‘waiting for’ something or someone else to take the pain away.  It’s also worth remembering that, like changing any habit, it will take time for the new skills to become automatic.  And, like any other habit, there is a good chance that once a person goes to a new situation, the ‘old habits’ might die hard.  Skills that are relatively easy to use at home might be harder to apply in a work place; and most people need some reminders or ongoing support, at least initially, to persist with using skills that are more challenging, newer or have a slower ‘payoff’ than ways of coping they’ve used in the past.

To make the most of a referral for pain management, the following steps help:

1. Clarify the specific goals of the programme – to develop skills (eg coping statements, exercise programme, relaxation training, attention management), or to be able to carry out certain activities (eg walking further, carrying more, sitting longer, sleeping longer), or both?
2. Ask what skills the person needs to develop, and how they will know the programme has made a difference – this needs to be more than ‘I feel better’.
3. Ensure there is a link between the pain management team and both the employer (if there is one – if not, the vocational provider) and the medical health provider.  This makes sure the messages between these groups are consistent and clarifies expectations.
4. Work with the person, the pain management team, the employer and the medical health provider to identify what the next best steps for returning to work might be. 
5. Identify supports the person might need to integrate the pain management skills into the work situation.  This might take the form of at-work support from someone from the pain management programme such as an occupational therapist or physiotherapist, periodic follow-up sessions away from the workplace with the pain management team, or case conferences where the whole team can discuss progress and work through problems together. 

Pain management has helped many people learn to work ‘with’ their pain rather than fight to control it.  This doesn’t mean the battle is over, however! Regaining confidence, and achieving consistency or reliability when carrying out everyday activities is not a straight-line process.  Slip-ups or times when the person forgets to use pain management strategies are common and to be expected. 

Fluctuations in pain intensity are also expected and it is possible that people can confuse a flare-up of pain with a slip-up in using pain management strategies.  Pain management strategies don’t directly reduce pain intensity, and when increasing activity levels, pain intensity can also increase.  During flare-ups people can forget to use coping strategies, or may find it harder to remember to use, or use them effectively.  It’s at these times that it might be helpful to remind the person to review any worksheets or resources that they’ve been given during pain management, and especially any ‘set-back planning’ they’ve done.  At the same time it’s important not to redirect the person to new investigations or attempts to find a medical solution to their pain.  It can be hard to resist this, so if you’ve ensured the person’s GP has been involved (and any medical professional involved in the pain management team) this is the time to work with him or her to help the person remain focused on using pain management skills. 

If someone you’re working with has been referred for pain management, it’s a positive step.  It means the person will start making plans for their future, and taking the next steps toward independence.