This content is designed for the participants of the GGC Pain Management Programme.

Pain and fear part 2

Slide 1

What can we do when we recognise that it is fear of pain or harm that has contributed to avoidant behaviours?

We can think about our thinking. With the help of the psychologists on the team, we can explore what role our thinking plays in keeping us in vicious cycles with our pain and our behaviours. Often we find that we have formed quite strong beliefs about our pain, or maybe it was something a health professional once said that has really stuck.

We can use strategies that help us notice our thoughts and learn new ways to respond to them. Please take the time to listen to our presentations on our thoughts and what our thinking has to do with our pain.

Understanding more about our pain helps us recognise that the nervous system has learned how to protect us and is using pain to reinforce certain learned behaviours. E.g. it feels safer not to bend over, I feel less anxious when I don’t go out. The nervous system thinks it’s helping us but staying stuck in these cycles.

The nervous system can learn new things and remember, tissue healing took place a long time ago and pain does not mean more damage.

Graded exposure is a technique that helps us gradually explore getting used to something that feels quite threatening and realising that we don’t need to be as afraid anymore. You will have heard stories of people who learn not to be afraid of spiders, or of flying by using graded exposure techniques.

It train the brain by learning through experience that things are not as bad as we predicted they would be. But if we never try, we’ll never know.

Graded activity, or pacing can also play a role in overcoming fear and avoidance as it helps build confidence over time. We have a presentation called activity options which goes into this in detail.

And last but not least, ask yourself what difference it would make if you could rediscover this movement or activity and no longer avoid it.

The evidence from research tells us that fear avoidance is reduced when we can identify something of greater importance. We have worked with a great many patients who return to levels of activity they had not thought they would be able to once that fear has been reduced.

We have a talk on values and goals that will help you think more about what you would like to aim towards.

Slide 2

Think about the movements or activities you have been avoiding.

Think about what you would like to be able to do. Recognise where you are at the moment. Is it fear that is stopping you from taking the steps towards what matters to you?

The only way you can get to where you want to be is to break the process down into manageable steps. Experience has taught you that if you push too hard the pain gets worse and even if you avoid the activity it only seems to make things harder in the long run.

It might help to have an example of what we mean by this.

Slide 3

Meet Susan.

Susan came to the pain service in 2017 with ongoing back pain in her thoracic spine. She had fallen in the garden 2 years previous and since then had developed persistent pain and a real fear that she could cause more damage to her back with certain activities. She had been diagnosed with osteoporosis and had sustained a fracture in one of her vertebrae. Because of this, she worried that her spine was fragile and could easily break if she wasn't careful.

Susan had stopped lifting anything that had any weight to it and worried about going out on her bike.

Susan attended for specialist physiotherapy where she gradually build up he confidence to bend and turn her back. But she still worried a great deal and recognised that this was affecting her mood and her social life. She was referred to the pain management programme and over the weeks she attended she made great progress with working towards her goal.

The PMP coincided with the due date for her first grandchild’s birth. Susan recognised that when the new baby arrived she might be fearful to hold her grandchild. She found this though so upsetting that she set a goal of being able to hold a lift a weight comparable to a baby ahead of the birth.

Susan started to practice holding a water bottle in her arms talking around the house until she felt her confidence improve. She practised bending over and placing the bottle down and picking it back up again. Over time she increased the weight of the object and the length of time she could hold it for. She stuck to her goal because it mattered so much to her even when others around sometimes made unhelpful remarks.

Slide 4

Susan achieved her goal!

She was able to feel confident to hold her new baby gran-daughter when she arrived and be a hands-on granny. As the baby grew bigger Susan was able to carry her and feel strong enough to push the pram.

Since then Susan and her family have welcomed a second baby girl into the family and Susan told me she hasn’t looked back.

She no longer feels the same fear about her back and is able to focus on the things that matter.

Memory is a powerful thing. Susan’s previous memory of the fall had kept her in a place where she had to play it safe and avoid any threatening movements or activities.

If pain is sufficient to stop you doing the things you enjoy, it keeps you in a place of continued worry and avoidance. Evidence suggests that remaining anxious about the pain can actually make the sensation of pain worse.

What if we start to think differently about pain and how the nervous system has become conditioned to respond in an automatic way.

Susan’s story tells us that the nervous system can adapt when we go about things slowly and consistently, while at the same time deciding that this is worth our while.

Can you think about a similar examples of things you are avoiding because you have learned through bad experience? Could you come up with an idea of where to start and what steps you could take to start practicing the movement in an easier way?

Ask yourself what it is you most worry about when you think about these things.

Do you feel any of the fight or flight responses happening in your body when you think about the movement or when you try the movement?

Slide 5

These are other examples we have been given by patients of movements and activities that they had learned to avoid but with practice re-introduced.

Can you relate to any of these?

What difference might it make if you could learn to reduce the fear associated with movements like this and be able to manage again?

Slide 6

We would encourage you to confront some of the movements or activities you have been avoiding if you feel they are interfering with what is important to you.

Using these scales might help you decide what you are willing to try.

Ask yourself the questions above before, during and after the movement and see what you notice.

This is an experiment and there will be a good bit of trial and error involved here, but it’s important to aim for low anxiety and higher confidence. There is likely to be pain but we would encourage you to recognise whether you are tempted to push through pain or to avoid pain as you try this.

Slide 7

We would recommend you take some time to watch this short video on youtube .com which covers some of what we’ve been thinking about today.

Slide 8

This is another clip which addresses the importance of looking at our beliefs about pain and how fear of damaging our bodies can really affect how we move.

It is specific to back pain but still makes for an interesting watch even if you have pain in other places.

Slide 9

Our experience of pain can lead to the development of a fear associated with specific movements, tasks and activities. This fear then prevents us from engaging in that particular activity and can lead to avoiding it all together. In some cases, even the thought of doing it, or watching someone else do the movement or activity you struggle with can cause an increase in pain and trigger a reaction in your nervous system known as fight or flight.

We become conditioned to respond this way as the brain starts to feel safer when we avoid.

With the help of pain management strategies, people are able to use certain techniques combining thinking and movement strategies to help then explore the things they fear in a gradual way, building up bit by bit.

A greater understanding of pain can help reduce the worry about pain meaning damage and this allows people to feel more confident to try things again knowing they are not causing tissue damage to themselves. Over time, this can help people re-engage with movements and activities which matter to them and improve their quality of life.

Please take time to write down anything that you wish to discuss at your next appointment.

This is the end of this presentation.

Thanks for listening

End of video script

Return to preparation for session 7