The document describes a COPE with Pain training program that uses cognitive behavioral therapy techniques to help patients better understand and manage chronic pain. The goal is to (1) help patients understand their pain, (2) increase function through coping strategies, and (3) rewire brain-pain pathways. The training introduces exercises to retrain the brain, including identifying left vs. right body parts, using the non-dominant hand/leg for activities, visualization, and graded activity pacing combined with relaxation techniques.

1. COPE with Pain Training Series
Up Pain
Down Pain
Good Brain
Bad Brain

2. What is Chronic Pain and How can we COPE with Pain?
The important role brain and emotions play in chronic pain is
well recognized in the psychological and medical literature.
Pain is both a sensation from an injury area as well as our
emotional and brain response to the pain.
Pain is a deeply personal (subjective) experience; no one else
can experience how your pain feels

3. The goal of the COPE with Pain program is to assist
patients with chronic pain
(#1) understand their pain,
(#2) increase function by COPING with their pain, and
(#3) re-wire their brain-pain pathways
Your COPE with Pain Psychologist will introduce you to
COGNITIVE BEHAVIORAL THERAPY (CBT) techniques that
‘push through’ the emotions as well as the pain.
**CBT will be used in tandem with your physicians’ medical pain management therapies.

4. When the body has an injury
….neurotransmitter signals travel up
the small peripheral nerves
….through a ‘gate’
and then up the
spinal cord
…then to the
brain
This is ‘Up Pain’
Let’s explain how the Pain Brain works so CBT makes sense!

5. This is ‘Good Brain’
…then it passes through the ‘emotional’
area of the brain
Pain first arrives in the ‘fight
or flight’ part of the brain
..then to the
‘thinking’ part of
the brain
…finally to
the ‘action’
part of the
brain

6. …..and the ‘plan’ tells the
injured area to move out of
harm’s way
…the pain signal has
to pass back though
the ‘gate’
…the ‘action’
part of the
brain sends a
‘intention’
(plan) back
down to the
injured body
area
This is ‘Down Pain’

7. This is ‘Bad Brain’
When the brain ‘turns on’ the pain receptors for a
long period of time (Chronic Pain)….
The brain ‘smudges’ pain beyond the area of the
original acute pain
The ‘Pain Switch’
can get stuck in the ‘ON’ position

8. This is ‘Bad Brain’
But the way we think and feel about our pain has a
significant and long lasting effect on our painbrain
It is natural to have negative, angry and fearful
thoughts and feelings about our pain
Our primal brain starts a fight-flight or freeze response
that triggers these thoughts and emotions
We end up living in our emotional brain instead of our
thinking brain

9. This is really ‘Bad Brain’
The long term opioid pain medications you may
be taking ‘sedate’ the thinking brain and
‘reward’ the emotional brain
Our emotional brain reward system becomes
dependent on the drugs and leads to a drug
‘craving’ that is associated as pain

10. We can learn Cognitive (the way we think) and
Behavioral (actions we take) therapies to re-train
the brain back to the way it was before the
chronic pain.

11. We have two sides to the brain and each brain
area controls specific movements
the RIGHT
side of the
Body is
controlled by
the LEFT side
of the Brain
the LEFT
side of the
Body is
controlled by
the RIGHT
side of the
Brain

12. and each body part has a different area in the
brain that controls those movement
As we practice an
activity (like
moving our LEFT
hand) we create a
BRAIN MAP in a
RIGHT BRAIN area
dedicated to LEFT
arm movements

13. The first exercise to re-train the brain will be to
identify the RIGHT versus LEFT side of the body,
therefore re-distinguishing the ‘SMUDGED’ RIGHT
versus LEFT sides of the brain

14. The second exercise to re-train the brain will be to
to practice using your less Dominant HAND and
LEG for day to day activities

15. The third exercise to re-train the brain will be to
exercise the LOCALIZED motor areas of the brain
that have become ‘smudged’, through exercises
called Visualization and
Graded Activity Pacing

16. First Exercise: Identifying
LEFT vs. RIGHT
EASY
LEFT
Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow

17. First Exercise: Identifying
LEFT vs. RIGHT
HARDER
Click on the Right or Left Arrow
to match the Hand in the TOP CENTER
(it will not advance to the next slide until you click the correct arrow

18. First Exercise: Identifying
LEFT vs. RIGHT
HARDEST
Click on the Right or Left Arrow
to match the Hand in the TOP CENTER
(it will not advance to the next slide until you click the correct arrow

19. First Exercise: Now do these
RIGHT versus LEFT exercises
for a few minutes:
Work at your own pace, but try and get
faster each time this exercise is repeated

20. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

21. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

22. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

23. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

24. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

25. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

26. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

27. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

28. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

29. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

30. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

31. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

32. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

33. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

34. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

35. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

36. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

37. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

38. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
(it will not advance to the next slide until you click the correct arrow
RIGHT

39. Click on the Right or Left Arrow
to identify the RIGHT or LEFT hand
LEFT

40. Click on the Right or Left Arrow
to identify the matching hand
(it will not advance to the next slide until you click the correct arrow)

41. Click on the Right or Left Arrow
to identify the matching hand

42. Click on the Right or Left Arrow
to identify the matching hand

43. Click on the Right or Left Arrow
to identify the matching hand

44. Click on the Right or Left Arrow
to identify the matching hand
(it will not advance to the next slide until you click the correct arrow)

45. Click on the Right or Left Arrow
to identify the matching hand

46. Click on the Right or Left Arrow
to identify the matching hand

47. Second Exercise: Using your less Dominant HAND
and LEG for day to day activities
****Skip this exercise if your physician has advised you to NEVER use this hand and/ or leg

48. ****Skip this exercise if your physician has advised you to NEVER use this hand and/ or leg
Second
Exercise:
the purpose
of this
exercise is
exercise the
THINKING
part of the
brain.
This decreases
the activity in
the
EMOTIONAL
areas of the
brain, where
we derive much
of our pain
experience

49. Second Exercise: Make a list of activities you can
usefully do with your less dominant hand
****Skip this exercise if your physician has advised you to NEVER use this hand and/ or leg
 Drink
 Eat
 Open Doors
 Use the remote
 Dial your phone/text

50. Which is your dominant hand?
The one you normally write with.

51. Which is your dominant leg?
The one you normally lead with when you get up
from a chair.

52. Second Exercise: Make a list of activities you can
usefully do with your less dominant hand
****Skip this exercise if your physician has advised you to NEVER use this hand and/ or leg
 Drink
 Eat
 Open Doors
 Use the remote
 Dial your phone/text
Video demonstration is available at https://www.youtube.com/watch?v=QYCUviivvAg

53. Second Exercise:
When using your less dominant leg,
be ‘MINDFULL’ when you get up from a chair or
start to walk,
and lead with your less dominant leg
****Skip this exercise if your physician has advised you to NEVER use this hand and/ or leg

54. Second Exercise: Practice a few of these now and
then do them as HOMEWORK and Report back
how this went
****Skip this exercise if your physician has advised you to NEVER use this hand and/ or leg
 Drink
 Eat
 Open Doors
 Use the remote
 Dial your phone/text
 Lead with your less dominant leg

55. Third Exercise
Exercise the LOCALIZED motor areas of the brain
that have become ‘smudged’, through
visualization and an exercise called
‘Graded Activity Pacing

56. Visualization
Start with diaphragmatic breathing
Take 6 deep, slow breaths in through the nose
counting “one-two-three”, then exhale for a
count of three from your mouth.

57. Visualization
Now with your eyes closed, visualize yourself the
way you used to move before this injury or illness
Keep visualizing this activity
Each time you do this, you are re-energizing that
part of the brain that used to control those
nerves and motor function and extinguishing the
pain map part of the brain
** research shows you will have to practice 2 to 3 times a day
for 6 weeks to make this ‘stick’, but it can work!

58. Third Exercise:
Graded Activity Pacing
Remember the GATE that was
introduced at the beginning. We are
going to use ACTIVITY to close the GATE
and reduce the pain signals that are
coming back down from the brain
A video demonstration is available at
https://www.youtube.com/watch?v=TYMMh7i8qfM

59. You are going to bite down on your bottom
lip with your top teeth
Use the Pain Scale from 1 to 10, and when
you begin slowly increase the bite pressure
from
1 to 2 to 3 to 4 and then only to a 5
(move to the next slide to begin)

60. You will put up a hand with your
fist closed and put up one finger
when you move to a 1, two
fingers for a 2, etc
(wait for the next slide to begin)

61. (Now move to the next slide
for the next instructions)
OK, start biting: Harder to a 1
Harder to a 2
Harder to a 3
Harder to a 4
Harder to a 5

62. (Now move to the next slide
for the next instructions)
Keep biting at a 5
And now shake your hand
Shake your hand
Shake your hand
Stop Shaking

63. Where did the pain go?
The explanation is that the body has
two sets of nerves
The small nerves are where pain travels
The GATE sets a priority on the large nerves
and shuts the GATE on the small nerves
when we are active
So as much movement as we
can tolerate is very helpful
The large nerves we use for movement

64. Graded Activity Pacing
(1) Choose an activity that increases your pain when you
do it (or that could increase your pain)
(2) Keep track of how long you can do it without causing
you more pain
(3) Redefine your activity time: it’s some minutes less
than the time you considered at point 2
(4) Define your rest time: it’s the time you need to rest
before restart your activity in order to avoid feeling more
pain

65. When resting between activities, use the techniques
introduced to you in CBT
(1) Deep breathing
(2) Progressive muscle relaxation
(3) Mindfulness meditation
(4) Self hypnosis
These techniques all promote increased oxygenated blood
flow, anti-inflammation and a sense of emotional well-being,
and will allow you to get back to activity sooner
Enhanced Recovery for Graded Activity Pacing

66. COPE with Pain Training Series
Up Pain
Down Pain
Good Brain
Bad Brain