Case-Based Review

Nonpharmacologic Treatment of Chronic Pain—A Critical Domains Approach

Journal of Clinical Outcomes Management. 2016 February;23(2)

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During the visit, Lisa reported a loss of joy in her life and then began crying. Such a report should prompt a more formal exploration of the potential for depression. She would likely benefit from antidepressant medication and behavioral intervention. The physical activity prescribed above will also pertain to treating her depressive symptoms as will strategies to improve her emotional well-being, sleep and stress noted below. Perhaps the most beneficial strategy would be to refer her to CBT for pain and depressive symptoms. CBT for pain would help Lisa acquire the skills required to address many ExPRESS [10] domains including increasing physical activity, improving mood, decreasing stress, and improving sleep.

What strategy can be recommended to help patients regain function?

Regaining Function

Pain is disruptive. Patients with pain may avoid activity due to fear of re-injury or making the pain worse. Pain may keep them awake at night and lead to daytime fatigue. Pain can be so bad that a patient cannot even do simple tasks, One of the most important goals in successfully managing pain is to move away from trying to cure the pain and instead focus on regaining function—helping the patient do some of the things he/she really wants to do despite the pain. The patient may not be able to all the things he/she used to do, but new ways to do many of these activities can be found. Patients can also identify new rewarding activities to do now that things have changed.

To regain function, an evidence-based strategy comes from behavior therapy and is known as graded activation [42–46]. Here the patient is assigned one very small, manageable and incremental step towards achieving a goal. As these small goals are met, the patient feels motivated to engage in more and larger goals.

Lisa specifically mentioned giving up valued activities in light of her chronic pain. To help her re-engage a graded task assignment approach can be taken. For example, Lisa would be encouraged to first identify an activity she would like to get back to doing again. If she were to say “gardening,” then she is to next identify one small, specific, and easily achievable goal for the short term, such as “garden for 20 minutes at least once in the next week.” Help her identify the roadblocks to completing this small goal and brainstorm solutions such as “My kids have soccer and basketball practices 5 days next week so I will ask my ex-husband take them to practice at least one day next week so I can spend time in my garden.” Lisa will be told to schedule time to garden as if it were an appointment with a doctor.

Another important issue to consider is the tendency for inconsistent levels of activities across days that are predicated on how one feels that particular day. On “good days” often patients inadvertently engage in more activity than personal limitations allow and as a consequence experience several “bad days” of pain and other symptom flare up which can result in lost productivity and worse self-esteem. The goal is to have patients engage in a moderate amount of activity every day and avoid activity “binges” or days with little of no activity. Graded activation is a method of pacing that can improve physical functioning while minimizing the likelihood of pain flare-ups.