This document discusses strategies for addressing persistent pain in 10 minutes. It emphasizes understanding the patient's story and pain from a biopsychosocial perspective. The clinician should listen empathetically, provide a neuroscience-informed explanation for the pain, and collaboratively make a plan focusing on outcomes rather than symptoms. Explaining pain reduces the perceived threat and can change pain. The goal is for the patient to become their own "pain coach" and independently manage their condition.

1. PERSISTENT PAIN:
WHAT YOU CAN DO IN 10 MINUTES?
Richmond Stace MCSP MSc (Pain) BSc (Hons)
Specialist Pain Physiotherapist

2. patient
 Low back pain
 Headaches
 Multiple joint pain
 IBS
 Anxiety & low mood
 Picture the patient…..sitting in your office

3. First thoughts and feelings?
 Interested?
 Curious?
 Anxious?
 Frustrated?
 Excited?
 Worried?

4. Inner consultation
 What is your inner dialogue?
 What are you telling yourself?
 What questions are you asking yourself?
 Impact upon the consultation?
 Impact upon the person?
 Effect on next patient?

5. The problem of pain
 A systematic analysis for the Global Burden of
Disease (Vos et al. 2012)
 No. 2 -- back and neck pain
 No. 10 – migraine
 No. 11 – osteoarthritis
 No. 1 – depression
 How many have pain & depression?
 How many people are in pain for all reasons?

6. What is pain?
 Protection
 A protective device
 A motivator
 Compels action
 Survival
 Adaptive
 To the person, it hurts

7. What if pain persists?
 Why in some people and not others?
 Why in this person?
 What do they tell you in their story?
 What don’t they tell you?

8. Pain vulnerabilities
 Why is there on-going protection?
 Reasons why pain may persist:
 Prior experiences of pain
 Kindling or priming
 Functional pain syndromes
 E.g./ IBS, pelvic pain, migraine
 Existing sensitivity
 On-going stress/anxiety
 Genetics

9. The story
 Patient story
 Needs validating
 We acknowledge their suffering with compassion
 Needs meaning
 How have they got to the present moment
 Nothing happens in isolation
 Gives clues…

10. Here’s a story…
 Leg pain 18/12, worsening
 Incident => pain but no injury
 Previous leg pain
 Sensitive digestive system
 Insomniac
 Has nothing to do with my pain
 I don’t have any stresses….
 About to start IVF

11. Pain
 Pain is not an accurate indicator of tissue
damage
 It is the person who experiences pain, not the
body part
 Shift in sense of self
 Pain is a response to a perceived threat
 Pain is experienced in a ‘space’
 What is threatening?
 A movement, an action, a thought?

12. What I am feeling now…
 Is the brain’s best guess
 Selection of a hypothesis
 What does all this sensory information infer?
 What does it infer based on what I know?
 What does it infer based on what has
happened before?
 Pain, pain, pain, pain, pain….
 A prediction

13. The person
 Beliefs
 Expectations
 Thoughts
 Movements & posturing
 Role in life: work, home
 Lifestyle patterns
 Ever changing….adapting…learning

14. The person in pain
 How do they change?
 Body sense
 Movement
 Planning
 Thinking
 Emotions
 Perception
 Self

15. What story are they telling
themselves?
 The story of their pain
 Cause and effect
 I must avoid….
 I can’t….

16. All consuming
 Pain can pervade into all aspects of existence
 Feeling
 Thinking
 Sensing
 The lived experience
 Moment by moment

17. Biology of pain?
 Where is it?
 Whole person
 Many body systems that protect
 Most of it is not where the pain is lived
 A thought about the pain is biology
 ‘Biology in the dark’

18. Where is the pain coming from?

19. What influences pain?
 The way we think about it; the meaning to ‘me’
 Beliefs about pain
 Attentional bias – vigilance to body
 Stress (threat)
 Tiredness – more sensitive, less resilient
 Context
 Environment
 Prior experience

20. Stress and pain
 Pain is a stressor
 Chronic stress => more inflamed
 Situation => perception/meaning => response
 Prepared for/reacting to perceived threat
 Systems ready
 Systems dampened: GI, reproductive

21. Think of a time…
 ….when you were feeling stressed
 How do you feel now?
 Where did you feel it?
 What did you feel it with?
 Your mind -- where is your mind?
 Embodied cognition
 No separation of body-brain-mind-environment
 ‘Whole person’

22. Sleep and pain
 Sleep problems appear to predict onset of
chronic pain
 Predict persistency and increase in pain levels
 Effect of pain on sleep less strong
 We need sleep! And a good period of sleep

23. Improving sleep
 Calm conditions before bed
 Bath, mindfulness, reading
 Associate bed with sleep
 Unhelpful thoughts – mindful practice
 Lifestyle patterns
 Eating time
 Refresh and renew through the day

24. Pause

25. Functional pain syndromes
 IBS
 Migraine
 Pelvic pain
 Dysmenorrhoea
 vulvodynia
 Fibromyalgia
 Often with:
 Anxiety
 Hypermobility

26. Functional Pain Syndromes (2)
 Vulnerable to persisting pain
 Common adaptations underpinning all
 Protection
 Perception of threat: cues & triggers widen
 Great example of need to tackle whole person

27. Getting better
 What is getting better?
 Who gets better?
 I am better
 The person gets better
 Who do we treat?

28. Who gets better?
 Those who understand their pain
 Those who use their working knowledge of
pain
 Those who use their strengths
 Those who persevere
 Those who focus on an outcome not the pain
 Those who see the flare-up as a challenge to
overcome
 Those who deal with distractions

29. What does an approach need?
 To be a lived experience
 Be available moment to moment
 Promote independence
 A focus on the outcome
 For the ‘action’ to change the prediction
 At any given moment

30. Pain Coach
 Coaching the person to become their own
coach
 What do I think? What do I do?
 Create the conditions for the desired outcome
 Outcome focused – their vision of healthy self
 A blend of pain neuroscience and strengths
based coaching
 Getting the best out of a person
 Maximising their potential

31. The early messages
 Set the scene
 Need to be accurate
 Need to answer:
 What is wrong?
 What do I need to do?
 What will you (clinician) do?
 How long will it take?

32. Mature Organism Model

33. 10 minutes to….
 Listen
 Work out what is happening
 Explain
 Make a plan
 Take some action
 Patient’s perception of the consultation?
 Their reality

34. How long does it take for pain to change?
 Pain – No pain
 On – off
 Pain is not constant
 Each moment is new
 Each moment is an opportunity
 You cannot not change!

35. The potency of you…know
that…
 Behind your words
 Knowledge
 Insight
 Understanding
 A trusted advisor, a coach
 You are a ‘drug’ affecting their physiology
 Compassion
 Approach
 Words of advice

36. Understand pain
 Understand pain to change pain – explain it
 What is pain?
 What is their pain about?
 Specific to them and their story
 Creates a foundation to start reducing threat
 Working knowledge: what do I think? What do I
do?
 Independence, control, empowered
 Pain is about perceived threat
 Reduce the threat = reduce pain

37. UP | Understand Pain
 @upandsing
 understandpain.co
m

38. Actions (1)
 Referral
 Reasons explained
 Investigation(s)
 Reasons explained
 Lifestyle advice
 Reasons explained
 Influencing pain; e.g. sleep pattern, stress

39. Actions (2)
 Further information
 Quality reading material, website
 Medication
 Reasons and explanation of how it works
 Expectations primed
 Foundation of understanding that
creates ‘safety’, confidence and
motivation
 Changing their perception/relationship
with pain

40. For you: keeping your clarity
 Focused attention (mindfulness)
 Breathing between patients
 Movement between patients
 Greeting style as a way to shape session
 Actions emerge from clear thinking,
engagement & compassion

41. The person needs to…
 Understand their pain
 Understand what influences their pain
 Understand what they can and must do
 Understand that their pain can and does
change
 Show them and give examples
 Focus on their desired outcome
 Know they are believed and supported

42. Pain Coach
 Coaching the person to be
their own coach
 Realise their independence
 Moment to moment decisions
 Moment to moment actions
 Pointed towards desired
outcome
 Optimising potential
 Resume a meaningful life
 I feel like ‘me’ again

43. And relax

44. Thank you
 www.understandpain.com
 www.specialistpainphysio.com
 @painphysio
 @upandsing
 painphysiolondon@gmail.com