As I understand it, the things you should do about chronic pain without identifiable and fixable physical causes are movement, psychology and understanding (not necessarily in that order).
Regarding movement, if there are exercises that can be done without pain, do them and progressively increase the duration or load. What do you do if there are periods during which the pain is too much to exercise (lift, walk, whatever) or the pain fluctuates seemingly at random? Just persevere?
Regarding psychology, reduce anxiety and catastrophizing. Do you have specific suggestions for doing this, such as a step-by-step program (you had previously recommend online CBT, but we haven’t found something that looks good)? Do you have a recommendation for a doctor or therapist in New York City?
Regarding understanding, you have posted a lot of information on the biopsychosocial model, so we seem to have that under control. Unfortunately, the materials I’ve seen have not contained enough specifics on treatment to be operational.
63 year old female, No other serious medical issues, just hip pain which can radiate down her leg, sometimes to the heel.
It’s not thought to be hip osteoarthritis. MRI showed only normal spinal degeneration. Physical evaluation (manipulate leg in various directions) resulted in a diagnosis of issues with lumbar and sciatic nerves. One round of lumbar and sciatic nerve injections (cortisone and anesthetic) seemed helpful for months (pain turned to soreness and she was able to walk relatively pain free, albeit slowly). A recent second round of lumbar injections seemed to increase pain, although that has abated.
She often has immediate reactions to emotional events, e.g., if she gets upset or a dog barks at her when we’re walking, her pain will spike.
I hope this answers your question without going too far into a tangent.
For your first question in OP, I usually work with people to re-frame their symptom fluctuation to minimize fear, ensure they are not catastrophizing, and find some sort of movement that they can tolerate that can be worked through. If there are underlying psychiatric issues like anxiety, etc., these need to be dealt with as well. Constantly ruminating on symptoms is unhelpful. Additionally, the more helpless they feel in the face of these symptom fluctuations, the worse their prognosis is (this sense of helplessness is a component of catastrophizing), so they need to feel that they have some degree of control over the symptoms. Not that they can “think” their pain away, but that they can control their thought processes, behavioral responses, and physical responses (i.e., willingness to move in the face of discomfort).
See above. If you need help, you’ll need to seek out professional help from a pain psychologist, for example. I don’t know anyone in NYC.
I don’t know what you mean by this. Butler and Moseley have published a number of books directed at patients for this sort of thing.
I read Butler and Moseley’s Explain Pain. If I’m reading correctly, their suggestions for managing pain are understanding and internalizing the biopsychosocial model (especially the disconnect between pain and tissue harm) and graded exposure to movement, perhaps virtually if actual physical movement is an issue. Does that sound right? Am I missing something significant?
In your recent newsletter, you wrote: ‘So we need to “desensitize the system”, so to speak, using movement and deliberate cognitive strategies to address fear/catastrophizing and kinesiophobia.’
By movement, do you mean the graded exposure to movement?
Please say more about these “deliberate cognitive strategies” - what they would be and suggested implementation or exercises.
This is basically what we do with Cognitive Behavioral Therapy as it pertains to pain (though similar strategies are used in CBT for anxiety, panic, depression, etc).
For example, after teaching and internalizing the model, individuals should learn how to pay attention to their own thought processes and behavioral responses (metacognition). Then, once they identify things like catastrophizing and fear occurring, they have opportunities to practice the skill of actively manipulating these cognitive processes into more positive directions, to pull themselves back from falling into those rabbitholes and exacerbating their symptoms or perceived disability.
I get messages all the time from people who say they’ve just tweaked their back, and with this knowledge they immediately caught themselves starting to panic, and were able to re-direct things into a positive direction and continue moving around or training. That’s what I’m talking about. If you either 1) don’t understand the model, 2) can’t identify these negative processes, or 3) can’t actively take control of them and re-direct them, you’re likely to have worse outcomes.
Are there any CBT materials you’d recommend that are particularly relevant to chronic pain (or, if not, more general materials for catastrophizing, fear, etc.)?