Combine strategies to target chronic pain

Teaching self-management of chronic benign pain

Diabetic patients are taught to become active self-managers of their chronic condition, and that same concept can be applied to the management of chronic benign pain. At Kaiser Permanente Northern California in Oakland, a behaviorally based education program was developed to increase function so people with chronic pain can return to their normal activities of daily living. The program focuses on the physical, psychological, and social elements of pain management.

"Through the program, we try to move patients into an active self-management role of their chronic pain condition so that they feel they are in charge, instead of their chronic condition being in charge of them," explains Andrew Bertagnolli, PhD, chronic pain management program coordinator in the health education department of Kaiser Permanente Northern California.

Kaiser uses a multidisciplinary approach in its chronic benign pain management program. The team includes a physician to examine medication use and discuss the physical cause of pain and a health psychologist to address cognitive behavioral interventions for chronic pain, such as management of mood, assertiveness training, and cognitive reconditioning. Also included on the team are a physical therapist to address physical reconditioning and a nurse to handle the care management role.

Chronic pain is described in the literature as pain that lasts in duration for more than six months and well past the time a person would expect it to stop. With acute pain, there is a finite limit — the pain will end eventually — but with chronic benign pain, it will not. Chronic pain often has a snowball effect. The pain causes physical problems that begin to grow over time, leading to disruptions in mood, relationships, activities, and work functioning. "We may not be able to eliminate the physical source of the pain, but we can help people manage moods and other people and manage their activities," says Bertagnolli.

One of the main challenges of dealing with chronic benign pain is that it is subjective and varies from person to person. Its intensity is influenced by cultural, spiritual, and ethnic beliefs, and is also situational. "For some people, a prayer or meditation is going to be intuitively appealing based on their cultural background. For other people, that is not going to be part of a comprehensive pain management strategy," says Arne Boudewyn, PhD, chronic pain management program coordinator for Kaiser Permanente Northern California.

The program uses proven tactics such as management of mood, management of other people, management of activities, and behavioral reactivation. These topics and concepts are introduced to patients through a treatment group, and they learn to fit these concepts into their belief system.

For example, cognitive restructuring would focus on negative attitudes or unhelpful thinking. If a patient woke up in the morning with so much pain that he or she didn’t want to get out of bed, the team would work with the patient to help him or her develop a more positive outlook. The team might encourage patients to think instead of how much better they would feel after getting up and doing a few stretching exercises. "We help them identify unhelpful thoughts or unhelpful thinking patterns and challenge them into developing more helpful strategies in terms of new thoughts," explains Bertagnolli.

Cognitive restructuring is an important element of the program. People with chronic benign pain need to identify unhelpful thinking styles and begin to develop more helpful thinking patterns if pain is to be controlled. Other elements of the program include developing a daily physical exercise regimen and daily relaxation exercises to prevent pain flare-ups.

To learn techniques and strategies that fit their treatment plan, patients participate in a group educational setting for eight to 10 weeks. The sessions run about two hours each week and offer a mix of education and application. A physical therapist might cover posture positioning to control pain. A physician may talk about the pros and cons of pain medication and how pain is communicated to the body. Each week, patients do homework in order to apply what they are learning.

The program helps participants overcome many barriers to pain management. In addition to negative thought processes, many people are fearful of doing anything that will exacerbate the pain. They are used to the acute pain model in which the pain signals that something is wrong. With chronic pain, the signal is still there, but there is no damage occurring.

Also, patients sometimes feel that the only answer is passive treatment, such as taking a medication or having a procedure. Yet, when they assess their pain on a scale of one to 10 and look back over time, they are able to see how some of the strategies of the program have reduced their pain. "Many feel that their pain is at a constant level and never varies, and that makes it unbearable. The scale shows them that it varies," says Bertagnolli.

The pain may be a nine one day and a seven the next because the patient went to a movie and was distracted, or the patient exercised or did something he or she enjoyed. Generally, most people who suffer from chronic pain cut out the pleasant activities first so they have the energy to do their chores. This can lead to depression.

"We want to shift them away from being a passive recipient to an active self-manager," says Bertagnolli.

For more information, contact Andrew Bertagnolli, PhD, chronic pain management program coordinator, or Arne Boudewyn, PhD, chronic pain management program coordinator, Kaiser Permanente Northern California, 1950 Franklin St., 13th fl., Oakland, CA 94612. Telephone: (510) 987-1301. Fax: (510) 873-5379. E-mail: or arne.