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Persistent pain

What is persistent pain?

0 No pain
1 to 2 Hurts just a little
3 to 4 Hurts but bearable
5 to 6 Hurts and is distracting
7 to 8 Hurts a lot
9 to 10 Unbearable pain

Persistent pain is complicated and we don’t fully understand why some people go on to develop persistent pain and other people do not.

Persistent pain is pain that has continued for longer than 3 months and is often due to a combination of factors, including:

  1. A chronic condition, such as Osteoarthritis.
  2. An initial physical cause of pain, where the pain continues after the expected healing time. Most soft tissue and bone injuries heal within 3 to 6 months.
  3. Increased sensitivity of the nervous system. The nervous system becomes so sensitive it reacts quicker, needing fewer stimuli to generate a painful response. Pain often extends beyond the initial injury or site of pain because joining nerves also become stimulated and don’t turn off. Normal movement can become painful.
  4. Pain often causes a change in activity level and how we move; this often leads to stiffer and more painful joints and muscles, which can contribute to pain.
  5. Pain can cause low mood, anxiety, anger, stress, weight gain, lack of sleep, all of these factors then increase pain, increase the sensitivity of the nervous system and affect our ability to cope with the pain.

Increased sensitivity of the nervous system is often compared to a faulty car alarm, which is so sensitive it goes off without anyone touching the car.

Pain impacts every part of a person’s life. For example, if the pain makes you feel depressed, low mood, negative thoughts and lack of motivation will affect your pain, activity level, sleep, work.

We often think persistent pain is a sign of harm and that more pain equals more damage.

This isn’t always true. If you look again at points 3 to 5 above, we can identify why this might be the case. It was once thought that the amount of pain felt was directly related to the amount of injury. We now know this is incorrect, and that is it much more complicated. The brain uses all of the information from the pain cycle above to determine the level of pain felt.

If an injury was the sole indicator of pain, how would you explain the following scenarios:

  • The person with phantom limb pain, experiencing severe pain in the foot following amputation of the whole leg.
  • The shark attack victim that doesn’t experience any pain.
  • The person with hypo allodynia where slight touch triggers pain.

The brain decides the level of pain, this doesn’t mean the pain is all in your head or that you are making the pain up. It means that it is more complicated and that we cannot manage pain without looking at all of the
things in the pain cycle.

Consider how your pain affects you:

  • physically
  • mentally
  • socially

Using a traditional medical model (using medication) to try to find a cure or fix doesn’t help because we don’t have a cure for persistent pain, but we do have techniques that can help to manage it better.

Please watch the YouTube video by Professor Lorimer Mosely titled The Pain Revolution, April 2017:

Useful information

How can a pain management programme help?

  • Through education and non-medical management of persistent pain.
  • Acceptance: “Acceptance is not about giving up but recognising that you need to take more control with regards to how you can better self-manage your pain” (Pete Moore, The Pain Toolkit). If you are constantly trying to fight the pain or push through the pain or delaying things until the pain is better, this leads to reduced activity and increased frustration.
  • Taking control of your own pain management: Developing a pain management plan, implementing pacing and goal setting (information about this can be found later in this booklet).
  • Embracing change
  • Getting fitter and healthier: Pain often causes a change in activity level and how we move; this often leads to stiffer and more painful joints and muscles, which can contribute to pain. We aim to gently improve your fitness where possible. Being active and doing more can also have a positive effect on your mental health.
  • Improving your mood: Pain can stop you from doing the things you enjoy and creates a list of things you can no longer do, this is often a combination of pain, fear and anxiety.
  • Improving sleep
  • Relaxation and mindfulness
  • Through support from Leeds Community Pain Service, your friends and family.
  • By accessing other services or facilities that will support you to achieve your goals.

The aim of a pain management plan is to identify ways to improve the quality of your life, live a better life with the pain and manage your pain better.

The plan is unique to you because only you know how the pain affects you physically, emotionally and socially.

How to decide your priorities and where to start making a pain management plan

You can use your initial assessment via the pain toolkit to identify areas that affect you, or
you can use the list below (adapted from the Pain Toolkit).

  • Walking and moving about
  • Fitness and stamina
  • Exercise
  • Balance, do you have recurrent falls
  • Activities of daily living, washing,
    dressing
  • Pushing through the pain and causing more pain
  • Flare ups of pain
  • Understanding persistent pain
  • Acceptance, trying to move on from
    fighting the pain to management of persistent pain
  • Not having a diagnosis for your pain
  • Not understanding tests and investigations or terminology used
  • Sleep
  • Spending a lot of time in bed
  • Mood
  • Stress
  • Relationships
  • Work
  • Money worries, housing issues, adaptions to your home issues
  • Hobbies
  • Socialising or meeting family and friends
  • Isolation
  • Side effects or problems with analgesia

From the list above, please list the three which are most important to you to change or that you are willing to change.

Once you have decided what you want to change, you need to make a ‘pain management plan’ and set your goals. Please see the example below, there is also a blank chart for you to complete. The Leeds Community Pain Service can help you identify and set your goals.

What do you want to change? What is your current behaviour (baseline)? What are the barriers to change? Goals
I would like to increase my walking distance
  • I can walk for 2 minutes before my pain increases
  • I tend to potter around the house
  • I might walk for 2 minutes or longer once a week but this tends to cause a flare up of pain
  • Pain
  • Weakness of muscles
  • Motivation
  • Fear of making the pain worse
  • Walk for 1.5 minutes, 3 times a week, this can be very slowly increased every 2 weeks
  • Start daily stretches to reduce muscle fatigue
  • Walk with someone to improve my motivation

Please make a start at writing your goals down. Use the form below as a guide to developing SMART goals:

  • S: Simple
  • M: Measurable
  • A: Achievable
  • R: Realistic
  • T: Time limited

Do the following:

  • Complete the activity diary
  • Try the diaphragmatic breathing exercises

For example, your goal may be to walk to the shop. Start with a short walk and gradually increase the distance as you feel able. Set yourself a time limit, for example, 2 weeks and aim to have achieved the goal by that time.

This will lead to increased self-confidence, increased fitness and being more active which means you are ultimately in control. Start with what you can easily manage and build up slowly.

Try using this goal sheet to keep a record of your progress. If you are finding it hard to think of a goal, ask yourself:

  • “What do I really want to get back to?”
  • “What did I use to enjoy?”
  • “What would make my life a bit better now?”

Use this example for your activity goal:

Goal Target Day 1 Day 2 Day 3
For example, walking to the shop Walk 200 yards everyday      
       

Choose a time of day that is convenient to you and try and complete the target at the same time every day. As soon as you have completed a target, tick it off.

Activity diary

Completing an activity diary to aid goal setting.

This can highlight if you are doing more or less than you thought; if there is a pattern of activity and increased pain and if you have a good balance between work, rest and play.
Write in each box what you were doing, and how easy or hard it was for you to complete (0 easy to 10 extremely difficult).

Examples of things that you can record are watching TV, walking, washing up, going to the shops, lying in bed.

Example of an activity diary:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6am to 8am
8am to 10am
10am to 12am
Midday to 2pm
2pm to 4pm
4pm to 6pm
6pm to 8pm
8pm to 10pm
10pm to 12am

When we are in pain or feeling stressed, our muscles can become tense, this tension can further increase your pain. Relaxation techniques can help your body relax, reduce stress and anxiety and are an important part of long term pain management. Please look at our Relaxation and wellbeing handbook for more information.

This deep breathing technique can help you relax whenever you feel anxious or feel your breathing getting shallower or heavier. It can also be used to slow breathing down when hyperventilating (rapid breathing).

It is slower and deeper than normal breathing, and happens lower in the body (in the belly or abdomen), allowing the lungs to fully expand.

  • Relaxation breathing is a skill you will need to learn, techniques should be practised every day to have a more long-term effect.
  • Leave an interval of at least 30 minutes after eating as a full stomach can make relaxation more difficult.

Technique

  • Sit comfortably in a chair if possible.
  • Put your feet flat on the floor.
  • Shoulders down and jaw loose.
  • Back straight.
  • Loosen clothes around you stomach area if convenient.
  • Put one hand just above your stomach and one on the chest.
  • Breathe in through your nose rather than your mouth.
  • Your lower hand should move outwards as you breathe in to count of two.
  • Hold it for a count of two and then slowly breathe out to count of four, as your lower hand moves inwards.
  • Repeat twice and then relax and carry on with whatever you were doing.

Breathing should be obviously from the stomach not the chest as your lungs expand and push your tummy outwards. Try to keep the top hand fairly still. Only the bottom hand should move a lot as your lungs expand. If your top hand is moving more than your bottom, your breathing is likely to be more shallow.

Practise three time a day or whenever you feel anxious.
Take a moment to come back to the present after you carry out any relaxation exercise, and resume your next task slowly.

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