Pain Management Programmes
Chronic Pain Information

Pain Management programme at Frenchay Hospital, Bristol

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Pain Management Programmes and their structures vary at different centres, but overall they deliver the same message.

There are many aims of a Pain Management Programme (PMP). The principal ones are to:

• Improve fitness, mobility and posture, and counteract the effects of disuse of muscles and joints
• Counteract unhelpful beliefs and improve mood and confidence
• Avoid adverse drug effects
• Improve stress management
• Reduce the effects of pain on the family

PMPs teach a number of practical techniques and psychological strategies to enable a person with ongoing pain to maintain physical performance, optimise day to day functions, and reduce distress and suffering. The components usually include:

• Physiotherapy. A structured programme of stretches and exercises helps the patient regain fitness and flexibility. Patients are helped to identify their baseline activities, and learn how to build on this so that they, not the pain, control the amount of activity they are able to do, thus leading to improvements in their physical state. Individual exercise plans can be implemented where patients have particular problems, or the structured programme can be amended.
  
  
• Occupational Therapy. This helps patients identify activities, duties and hobbies that they want to return to, and teaches them how to achieve these tasks in a measured and controlled way without overdoing or straining themselves.
  
  
• Psychology. Many patients feel frustrated and angry because they cannot achieve tasks they have set themselves as they would wish, or they may feel anxious or panicky at times of increased pain. These thoughts and feelings can lead to low mood. Sessions with the PMP psychologist help identify these thoughts and feelings, and practical techniques are introduced to help their thoughts work for them rather than against them.
  
  
• Nursing. This programme looks at the medication being taken by the patient. Research shows that many drugs are unhelpful in treating chronic pain and often produce side-effects such as drowsiness, a dry mouth, constipation, and lack of concentration. The advantages and disadvantages of different types of medication are discussed and guidance is given on gradual reduction where possible and appropriate. Sleep difficulties are identified and discussed, and strategies to improve habits are taught.
  Relaxation skills are also taught to help patients cope better with pain and pain-related problems. The relaxation sessions start with simple techniques that focus on breathing and an overall reduction in muscle tension; other techniques are introduced to extend the patient's range of skills and their application.
  
  
• Education and Information. These sessions are aimed at providing patients with a greater understanding of the causes of pain (an injury that has usually healed), its effect upon the patient, and treatments available so that they are better informed for the future. All members of the team, including doctors, may participate in these sessions.

How you can get on a Pain Management Programme.

Many Pain Management Programmes will take referrals from your GP. Some patients are referred by their hospital consultant, and possibly by an anaesthetist attached to a pain clinic. Pain Management Programmes are different from pain clinics as the former look at teaching ways of coping and managing pain, rather than the pain relief.

The PMP I attended was run by Dr Nick Ambler at Frenchay Hospital, Bristol, BS16, UK

See http://www.btinternet.com/~thinkback/painman.htm for other addresses of Pain Management Programmes around the UK
Also http://www.spine-health.com/topics/conserv/psychol/cope/cope01.html
Also http://www.spine-health.com/topics/cd/neuropain/neuropain01.html

Frenchay Pain Management programme

I was initially referred to Dr Ambler from the Department of Neurosurgery at Frenchay Hospital. After a consultation with a psychologist on the team, who appraised me of the nature of PMPs, she put my name forward for the assessment session (a whole morning was required). The members of the Frenchay team were Nick (senior clinical psychologist), Mike (psychologist), Pete (physiotherapist) and Bev (occupational therapist), which is how they will be referred to below.

Assessment

Bev: using published occupational therapy and psychological assessment tests, we covered issues such as how the pain affects me now, and how it has been since the pain from the Tethered Cord Syndrome started in 2000, thereby affecting my daily life and emotions.

Mike: using tried and tested True and False cards containing specific statements relating to pain, we could assess how pain affects day to day living, dependence on other people, and, important to most people, their independence.

Pete: using simple body diagrams I could outline, "visualise" and "describe" the pain, its distribution and type. Symbols such as dots, dashes and shading helped to convey the different types of tethered cord syndrome pain.
Physical tests included standing up and down from a chair, arm circling, stepping up and down using a small stair, and walking between two fixed points and being timed/tested over a fixed distance. The fun bit was being filmed for gait analysis, which was used in the last session of the course to assess physical progress.

Week One

Our group consisted of 7 people, all with various underlying causes for our chronic pain, and all holding a variety of desired outcomes from the programme.

Bev: introduced a fundamental issue - PACING - upon which all parts of the PMP would be based

Pete: talked about the physical effects of pain, including my frustration that it continues, changing posture and gait to avoid pain, poor mobility and slowness, and avoidance of activities that induce the pain. He presented an assessment of different types of exercise and whether they would be possible or not for someone with chronic pain.

We also started the exercise programme. All were done at a slow pace, establishing baselines and assessing how the baselines could be built upon and fitness increased.

Smaller groups: Nick and Mike. An hour's session covered what we wanted to get out of the programme, management of the pain as it is, and trying to live with it, not be dominated by it.

Week Two

Pete: covered the theory and practice of exercise. New ones were added in, which were a good mixture of top and lower half exercises. They included heel raises which are a challenge for me as my left foot/ankle/calf muscles are so poor.

Academic Research Fellow: introduced the Gate Control Theory of Pain. She also did an informal questionnaire on the medication taken by the group members, and its effects on chronic pain.

Small groups: assessment of the first week on the PMP, how had it all been.

Week Three

Pete: asked for feedback on how the exercises were going. Everyone's counts were increasing. New exercises were added in for stretching to help with general fitness, as well as making tight muscles relax a bit and start to work again.

Nick: gave a talk on how we could "sabotage" the course if we wanted (not attending, not participating, not pacing, not doing the exercises, Dr shopping). He also introduced the idea of Three Islands in the life of someone with chronic pain: Wellville, Passive Island, and Active Copers. He asked us to assess where we thought we were at that time. My personal position varied from being an Active Coper when a flare-up disappears, but flare-ups regress me to my own personal Angry and Painful Island!

Bev: ran a relaxation session. Everyone, including the members of the PMP team, participated and felt very relaxed afterwards.

Small groups: assessment of the week. Ways of coping were outlined and discussed, including the need for pacing. Other issues for me were the need to work on the emotional and stressful response to the pain and flare-ups, and the projection of a negative/positive personal image. This was not an easy session and I felt emotionally drained afterwards.

Week Four

Pete: presented a brainstorming session on the daily practical issues of coping with pain, e.g. using washing machines, going to the cinema, basic housekeeping. He also added more exercises.

Bev: ran a session on sleep, which can suffer if a person lives with chronic pain.

Small groups: assessment of the week. Further goals were set. Personal pain had died down

Week Five

Nick: gave a long and extremely helpful presentation on flare-ups - their prevention, and how to cope with them when/if they occur.
How people feel when pain worsens - darkness, depression, grumpy, stress, catastrophising [this is it, this is the end, this is the pits, oh my god something has gone terribly wrong post-op].
Warning signs - niggles, burning feet, painful legs, burning pain in lower back/sacrum
Preparation for flare-ups (physically and emotionally) and the need for down-pacing when one is threatened.

Pete: exercise session. Personally I had progressed in a major way to be able to hop on my weak left foot!

Nick: covered personal image, the projection of passive-assertive-aggressive nuances. Levels of stress individualised.

Small groups: very hard emotional session. Probed deeper into the emotions around the pain and whole TCS situation. By the end of the morning a typical flare-up had started - dull aching pain, throbbing in back and legs.

Week Six

Nick: began by reviewing Neville Shone's book Coping Successfully with Pain. It is interesting reading and one participant had been enlightened by it and could see herself in the author's examples! She felt she could use this book and its advice in the future as part of her coping.

Pete: the last set of strengthening exercise was given to us. These were very uncomfortable for me as we had to lie supine on the floor and I still can't do that due to the scar hurting and setting up feet neuropathy. I had to modify the exercises, but still achieved what the others did.
I feel Pete's exercises are "safe" and I know they won't do much damage or cause a flare-up unless I do overstretch myself and then that is my fault anyway.

Small groups: my mood has lifted this week. Nick was very impressed with all my positive thoughts and said to keep tight hold of all those thoughts especially in a bad period, alongside better coping strategies.

Nick had set "homework" last week of putting down positive thoughts to hold onto when the bad days come along. A couple of mine were "I can educate others in this TCS journey, I am getting better at handling stress and anger, and am getting through the TCS episode much better than Ian had expected me to" [goodness, how much worse could it get!]?

Very tired and drained after this session but it was the best so far.

Week Seven

Pete: did a session on the avoidance of exercises, and how this is not a good strategy otherwise progress and fitness can be easily lost. I had found it was hard to fit in the exercises due to work demands and tiredness in the evenings. I would have to pace up the programme again to get back to what I had achieved 2 weeks previously.

Relatives session: reported to be useful to see how other family members cope/deal with chronic pain within the family unit.

Nick: gave another session about flare-ups. Reviewed how we were dealing with adaptive coping. He also ran a quick questionnaire on positive things to think about. Apparently people coping with chronic pain tend to find it harder to think about positive things (walking on the beach in the sunshine, a picnic with the family, a beauty pampering day, playing with children, etc.) and the bad pain days tend to crowd out the good days. We were encouraged to try to look beyond the pain and towards these positive things.

Small groups: covered the "uncertainty of the future" scenarios. Nick asked how I felt about the continuing pain and feet sensations. I still feel angry that the situation goes on, but I can't do anything about it so I just have to put up with the flare-ups when they come and try to avoid them by pacing.

Week Eight - last session

Small groups first: Nick began with a review of 8 weeks of the course.
I felt better able to cope with the bad periods but that was a combination of the PMP, anger management sections, and also the fact that the programme had forced me to take the problem out of the cupboard and face all my fears and concerns over the future with TCS. It also made me focus on it and how I might be able to cope with it all as I get older.

July 2004: this learning has continued, having had counselling since November 2003 to address my anger/stress/aggression/submission continuum]

Pete: a final exercise session. This was mostly guidance on how to keep going at home with the exercises. The pre-programme filming was reviewed: my physical progress had been subtle as I was very mobile at the start of the PMP, and this had not really changed. However, my physical progress had been in the strengthening of the lower limbs and the teaching of "safe" exercises.

Final session: review of the entire course and making appointments for individual reviews

End of course reviews

Pete: my test on exercises was better than at the initial assessment. I walked fast and longer than in the pre-programme assessment, felt less worn out and aching, although feet and legs still hurt.

Nick: the overall assessment was that I had done well physically and psychologically, and a good report would be sent to my GP and neurosurgeon. However, the downsides still remain.

Overall impression of Pain Management Programme

When I was accepted onto the Frenchay PMP, I was sceptical about its worth and whether I could actually benefit from it. Having experienced very poor, patronising, old fashioned and damaging psychology sessions years ago, I was wary of "counselling" and "group sessions". It conjoured up images of the old-style self-help groups ["my name is x and I am an x"]. However the PMP is nothing like all these preconceptions.

• All participants were made to feel so welcome at every session (tea and coffee available on arrival, for example!), pleasant surroundings, great support staff (receptionists and secretaries).
• No-one was made to feel a nuisance or an exception. We were all there due to the same overall reason (chronic pain), but each of us were treated with dignity and we felt as though someone, at last, cared enough about the ongoing pain to help us through it
  [Ian, please don't read this in the wrong way - I always appreciated the ways you tried to reassure me about all my fears and the referral was a godsend at just the right time].
• At the time of the operation I tried to deny the seriousness of the surgery and was not totally informed about life post-operatively. I feel that in the year after the surgery I was hoping for a miracle cure from the pain and unusual nerve pain sensations, and when this didn't happen, my mood plummeted.
  By the time I was referred to the PMP, my emotions and moods had hit rock bottom (see Personal Story) and I was very depressed about how it had all turned out.
  
• The PMP helped me to formulate coping strategies to both overcome the depression and to try to cope with the flare-ups as they come along. I could also reassess the future which is something I am still working on

The Pain Management Programme was an excellent combination of occupational therapy, physiotherapy and psychological help, using a holistic approach to overcoming the way chronic pain affects all parts of one's life. I would recommend it highly.