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Intermittent pain

Posted Jan 22 2009 5:14pm

I think intermittent pain must be one of the more challenging types of pain to have - one minute everything is going fine, then WHAMMO! out of the blue there is a bolt of electricity to hit the body.  The sort of pain I’m talking about here is primarily neuropathic pain, and I’m working with two people (and another one very soon) who have this pain.  One is an amputee with not only the WHAMMO type of electric shock pain, but also a nasty cramping phantom, and the other has intermittent noncardiac chest pain.

There are lots of types of neuropathic pain - in the last year or so I’ve worked with a couple of people with postsurgical neuropathic pain (lower back pain with intermittent leg pain), a couple of people with CRPS pain, one with diabetic neuropathic pain in both feet and stinging needle-type pain up and down the legs intermittently, another had facial pain after radiotherapy for a tumour.  So it’s not an uncommon pain, and it’s a challenging one to manage.

Most people will have a combination of medications to try to reduce the degree of pain experienced, but it rarely abolishes pain completely, and often it doesn’t appear to alter the stabbing electric shock pain as well as it does the deeper achey, cramping pain.

The people I’ve been working with recently have found it especially difficult to manage their pain because it does seem to hit them with a high intensity pain that rapidly increases their physiological arousal - so they experience, along with the pain, the increased heart rate, the altered respiration, sweating, trembling, feeling nauseous - and finding it really hard to think straight.

Most of the time I start with helping them become really skilled at managing their arousal level - self regulation.  This doesn’t change their pain, but it does help them have an active coping strategy to use while their pain is present and it reduces the secondary effects of getting ’stressed out’.  I’m not sure whether it’s simply having a distracting activity that reduces the feeling of being overwhelmed, whether it’s the sense of feeling more in control because at least they can regulate their breathing, or whether it is simply reducing their physiological arousal - but it does seem to be helpful.

Along with getting good at diaphragmatic breathing and then developing a sound relaxation response, I also use a cue word such as ‘relax’ or ‘I can get through this’.  I’ve taken to writing this down on a Can Cope Card (business card-sized cue card) so it can act as a prompt when they’re feeling a bit flustered by the pain intensity.  Usually I’ll head the card up with the word ‘STOP’, so it can act as a sort of thought-stopping technique.  I then write down ‘breathe out  s  l  o  w  l  y’, and then their cue word.  After that we work together to develop other appropriate coping strategies to list on the cue card.

More recently, I’ve added in something else especially for people who find their pain is not going to completely stop, it’s not responding completely to medication (or they can’t take medication because of side effects), and what I’ve been doing is talking about acceptance, and using mindfulness and acceptance together to help people ‘make space for’ their pain rather than fighting against it.

Our natural response to something alarming, especially something like pain, is to fight it. This increases the physiological arousal - which adds to the strain of the whole experience.  Paired with that response, we judge or evaluate the experience and try very hard to shut it out - which take a lot of effort.  And it doesn’t stop the pain!

So an alternative to fighting it is to simply stop fighting it.  Which is a whole lot easier to say than do!  It’s our natural response to not want to look the unpleasant in the eye and sit with it - we’d much rather it went away!

What I’ve been doing is teaching this process by starting with developing the relaxation response as I’ve described.  Next I discuss the futility of trying to fight with something that won’t go - ‘creative hopelessness’ it’s been called!

Then I take the person through a process of mindfulness - this is often simply sitting and allowing the mind to be aware of breathing…after a while, the mind wanders, and once the person is aware of this, bringing the mind back to focus on the breathing.  The scripts I’ve been using come from several mindfulness books I’ve found - one on Anxiety (The Mindfulness and Acceptance Workbook for Anxiety, written by John P. Forsyth,Georg H. Eifert, New Harbinger Press), and another called Learning ACT, written by Jason B. Luoma,Robyn D. Walser, New Harbinger Press.  I’ve found the anxiety one to be a really helpful book with some practical concepts that work well for chronic pain, especially intermittent pain, while the Learning ACT book is awesome, thorough - and for me, quite hard!

Once we’ve worked through mindfulness in breathing, I use the Wild Divine Health Rhythms biofeedback programmes, often one that has balloons, or rock stacking, as a means of helping the person notice their thoughts and allow them to pass without reacting to them.  This helps further develop the practice and skill of being aware of thoughts and feelings from a ‘wise observer’ viewpoint, rather than being in the middle of the emotions and thoughts.

And finally I use a script from the Anxiety workbook that talks about ‘giving space’ for the painful experience, approaching it and allowing the emotions to be, and being gentle and aware of it as you do so.

For one man, it’s been ‘wholing’ experience - what he means is, it’s helped him feel ‘whole’, made him become friends with his painful leg.

I don’t know that I would use the word ‘acceptance’ readily with the people I’m working with.  Instead I think I will continue with the concepts of ‘making room for’, ’sitting with’, or allowing it to happen.

I’m not sure that what I’m doing is anything new or groovy - but I am sure that people seem more comfortable with their pain, and it seems to take less time to pass.

      
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