Pain Management Meditations

What do we know about arthritis-related pain and its management? I have been studying the pain experienced by persons with rheumatic diseases for 20 years, and the more I learn, the more I realize that I don’t know. I would guess most rheumatologists and rheumatology health professionals feel the same. Understanding and managing pain remains a challenge for many reasons. Just a few of these include:

• Individual interpretation of pain intensity;
• Individual perception of living with pain;
• The relationship between pain and factors such as functional ability and affect (e.g., depression and anxiety); and
• The selection of pharmacological and nonpharmacological management strategies to “fit” the individual.

What I’ve Learned About Pain

I began my study of pain by developing a measure of the pain experience that has been very helpful in understanding the components of the pain experience as interpreted by the individual patient. Testing of the Chronic Pain Experience Instrument (CPEI) resulted in the identification of three dimensions: function, affect, and helplessness.¹ Probably most of us do not find these results surprising as we think about the experiences faced by people with arthritis. Revisiting the challenges listed above, we know that pain can affect function. Pain may, for example, affect how well one is able to walk, participate in activities that are personally enjoyable, pick up an object or a child, or perform work-related requirements.

When we think of affect, the often-asked question emerges: Does pain cause depression or anxiety, or do high levels of depression and/or anxiety cause pain? The probable answer is that there is a cyclical relationship between pain and affect. This relationship needs to be recognized in planning for pain management. Patients who feel helpless in the face of pain present a real challenge. Not only do they need to learn to use pain management strategies, but they must also believe that this will improve their outcomes. That patients can actually help manage their own pain though appropriate strategies is a belief essential to dealing with feelings of helplessness.

In clinical encounters, it is important to hear what persons with arthritis are saying when they talk about how they manage their pain and how they view the success of these efforts. Trying to make sense of these issues led me to do a concept analysis of pain management. The results have been very helpful; I now listen to personal descriptions and work with patients to plan useful strategies. The concept analysis resulted in three emergent dimensions: pain relief, pain modulation, and pain management self-efficacy.² I have found that discussing pain management within the context of these dimensions has been invaluable.

Definitions to Consider

Pain relief refers to easing or alleviating the pain, primarily by pharmacological management. When thinking about relief, patients can expect the lowering of pain intensity within a certain period of time or they can expect a tolerable maintenance of pain intensity level by an ongoing pharmacological protocol. Pain modulation refers to adjusting to or softening the effects of the pain using a variety of nonpharmacological management strategies. Methods such as distraction, relaxation techniques, or pacing activities to avoid overexertion represent ways that persons can modulate their pain over time.

Learning to use the methods that are appropriate to one’s lifestyle, functional ability, setting, and value structure is important; not every strategy is appropriate for every person. Over time and with practice, individuals can learn helpful strategies to soften the effects of pain or make their experience of living with it more positive. Pain management self-efficacy refers to persons’ beliefs that they can perform selected strategies that will modulate or relieve their pain. Increasing self-efficacy reduces the feelings of helplessness. A collaborative patient-provider approach is necessary to help patients learn to use pain management methods appropriately.

The overall definition of pain management gained from this concept analysis is “success in taking care of or handling the pain by using certain actions and by directing and controlling one’s own use of these actions.” This concept implies personal involvement and self-management.

Patient-Provider Partnership Key

One thing that we do know about arthritis-related pain and its management is that successful management requires the involvement of the individual. Success requires a partnership between the patient and the healthcare providers (e.g., physicians, nurse practitioners, physical therapists, and occupational therapists) involved in care. It seems safe to say that managing pain and the pain experience depend to a great extent on the person’s self-management, with the healthcare professional playing the supportive role.

There is growing awareness that individual behaviors can influence the symptoms of chronic disease, such as pain and activity limitations. The provider can prescribe medication, teach exercises and ways to perform activities of daily living, and teach management strategies (e.g., relaxation techniques, using activities for diversion, and using positive self-talk), but the individual patient decides whether or not to carry them out. Dialogue between the patient and professional is needed to determine the effectiveness of the techniques and the need for modification or changes.

We have great models of self-management, such as the self-management program begun at the Stanford Arthritis Center by Lorig and Fries.³ Individuals can now also access various Web sites that provide information about their conditions and approaches to managing them. These include the sites of the ACR (www.rheumatology.org/public/factsheets/index.asp), Arthritis Foundation (www.arthritis.org), Medline (www.nlm.nih.gov/medlineplus/arthritis.html), and the Centers for Disease Control (www.cdc.gov/arthritis). While many of the available written materials provide instructions for practice, whether these are accurately implemented by patients may be open to question. The involvement of the practitioner is, therefore, key to implementation through demonstration, guided practice, and evaluation.

Assessing the patient’s pain intensity, pain experience, and use of management methods is an important part of the professional’s supportive role when planning and evaluating treatment with the patient. There are numerous instruments available for the assessment of pain intensity, mostly one-item rating scales measuring pain from 0 (no pain) to 10 (pain as bad as it could be).

I have made two tools that I’ve developed available to you for use in your practice. One of these, the CPEI, measures the pain experience. The other—the Pain Management Inventory (PMI)—indexes what management methods the person is using and rates how often these are used and how helpful they are.⁴ These, along with instructions for scoring, may be downloaded from my Web site (http://myweb.twu.edu/~gdavis).

I know that all providers want to help their patients with their pain. I hope that my musings are helpful as you strive to meet this important goal in the treatment of patients with arthritis.

Dr. Davis is professor of nursing at Texas Women’s University in Denton and a member of the TR editorial board.

References

1. Davis GC. Revision of the chronic pain experience instrument (CPEI). Scientific Abstracts 1993; Abstract 67 (p. S343), 28th National Scientific Meeting, Arthritis Health Professions Association.
2. Davis GC. The meaning of pain management: A concept analysis. ANS Adv Nurs Sci. 1992;15:77-86.
3. Lorig K, Fries JF. The Arthritis Helpbook. 4th ed. Cambridge, Ma.: Da Capo Press; 2006.
4. Davis GC, Atwood JR. The development of a pain management inventory for patients with arthritis. J Adv Nurs. 1996;24:236-243.