Improving function is a key goal of persistent pain treatment1, 2, 3 along with supporting self-management, managing psychological and social factors,2 and minimising use of pain medicines, particularly opioids. To achieve optimal outcomes the patient’s treatment goals need to include resumption of meaningful and enjoyable activities, not just pain relief, with the aim to move from a pain-centred life to a function-centred life.4
Persistent pain can reduce the function and quality of a person’s life, and is associated with high levels of psychological distress, anxiety, and depression.5, 6
Persistent pain implies pain that lasts longer than one would expect or prefer and opens the possibility for change. The term ‘chronic’ may imply pain that is ‘unchangeable’ or may bring the connotation of being more severe and can be less helpful for patients as we focus on improving their function.4
Rather than being an indicator of ongoing injury or tissue damage, persistent pain is increasingly understood as a complex condition involving physical, psychological, social, and environmental factors, which can strongly influence a person’s experience of pain and their ability to function.2, 3, 8
For more information on understanding pain, see the Veterans’ MATES topic: Recovering from pain.
Persistent pain is complex and often challenging to manage.3 There are numerous evidence-based supporting approaches and resources, that you can use to help your patients understand their pain and feel supported. You can help your patient set goals that prioritise improving their function, enabling them to do the things they want to do.3
Increasing patient understanding of the neuroscience of pain can lead to better outcomes,9, 10 while a lack of understanding can contribute to feelings of depression, anxiety, and social isolation, which can further contribute to ongoing pain and decreased function.
Making time to help patients understand the nature of persistent pain, and how thoughts, emotions and behaviours can both influence their experience of pain and their function, is time well spent. Many resources can help you with this; see Box 1 for examples.
Allied health professionals, including psychologists, physiotherapists, exercise physiologists, occupational therapists, and pharmacists can also help patients gain an understanding of their pain and advise about strategies that may help patients achieve their desired level of function.
Talk to your patients about the goals of pain management and that self-managing their pain can enable them to do the things they want to do.2 Rather than focus on patient’s “pain scores”,2 shift to asking about their function (what they have been able to do) and quality of life.2 Helping a patient establish safe patterns of movement can help calm nervous system arousal and reduce central sensitisation.11
There are several tools available for assessing and monitoring function and identifying goals (Box 2) at all stages of pain management, including when attempting to reduce opioids.
A multidisciplinary approach is considered the most effective strategy for improving persistent pain.8, 12 Education regarding physical activity, cognitive, behavioural, and emotional strategies and general lifestyle, delivered in a multidisciplinary program can be effective in improving self-management and the patient’s belief in their ability to succeed.13
Access to specific multidisciplinary pain management programs is limited. Psychologists, physiotherapists, exercise physiologists, occupational therapists and mental health social workers may all be able to individually assist.
Encourage veterans to engage with a psychologist to help them. Psychologists can also develop an individualised treatment plan for patients with persistent pain.8 The plan could include teaching relaxation techniques, changing old beliefs about pain, building new coping skills, and addressing coexisting conditions8, 14 (such as post-traumatic stress disorder).
Other health professionals, including mental health occupational therapists and mental health social workers, can also help patients implement pain management strategies.
Occupational therapists may be useful in aspects of pain management including encouraging activity to reduce pain, developing patient confidence to participate in desired activities, and teaching safe movement in real-life situations.15 Social workers can work with patients to increase their community engagement, connections (e.g. with community groups), and activities. Physiotherapists and exercise physiologists can provide tailored exercise using a contemporary biopsychosocial understanding of persistent pain that focuses on activity and develops confidence whilst restoring and improving function.
The allied health treatment cycle aims to improve the quality of care for Veteran Card holders, is a way for general practitioners to refer eligible DVA clients to allied health providers. One treatment cycle lasts for 12 sessions or one year, whichever comes first. A veteran Gold Card or White Card holder with accepted service-related injuries or conditions can have as many cycles as their GP decides.
To find all the information you need about the Australian Government Department of Veterans’ Affairs (DVA) treatment cycle for allied health providers, go to: www.dva.gov.au/providers/notes-fee-schedules-and-guidelines/allied-health-treatment-cycle-and-referrals
The Open Arms service offers a group program for persistent pain, which may also support veteran education and engagement with multiple disciplines: www.openarms.gov.au/get-support/treatment-programs-and-workshops
There are some psychologists who have a particular interest in pain management. To find a psychologist go to www.psychology.org.au/find-a-psychologist, open the General Health option under Search by Issue and select Pain Management.
Try www.painaustralia.org.au/find-support/getting-the-right-care-1/pain-directory to find a local service.
See http://exerciseismedicine.com.au/wp-content/uploads/2020/05/EIM-FactSheet_Chronic-Pain_Professionals.pdf for suggested exercises for patients with chronic musculoskeletal pain.
Opioids can be effective for acute pain. There is no good evidence for benefit in persistent pain, only evidence of harm.2, 15, 16, 17
Long-term opioid use can have adverse effects which can have an impact on function, including cognitive effects, muscle weakness and loss of muscle mass, hyperalgesia (increased pain response whilst taking an opioid), endocrine adverse effects such as sexual dysfunction,2 and gynaecomastia.16, 18
Explain to the patient that long-term use of opioids for pain provides little benefit, and in most cases the harms outweigh the benefits. Explain that they do not usually need to be continued indefinitely, particularly if they are not helping to achieve individual goals such as improved function and quality of life. Ask patients about the impact of the opioid on their function, rather than focusing on its effectiveness for pain relief. For example, does drowsiness stop them doing what they want/need to do?
Opioids are no longer recommended for the treatment of persistent non-cancer pain.19 Some patients welcome the chance to cease their medicine but some will have concerns. They may be anxious about the consequences of stopping an opioid that has been prescribed for a long period or reluctant to stop an opioid when they believe it improves function.20 Explain that while tapering they will be supported and closely monitored for the best chance of success.21, 22 Box 4 has examples of deprescribing resources.
Explain to patients that many people with persistent non-cancer pain who take an opioid, may feel worse or find that the medicine doesn’t work as well the longer they take it. Stopping or reducing the dose may help them to feel more alert, to participate in more activities, and to experience less pain and less side effects.23
Whilst reducing opioids, encourage the ongoing use of non-drug treatments.17
Stopping opioids in people with persistent pain has been associated with long-term improvements in pain, function, quality of life,24 and less negative pain-related emotions and depressive symptoms. Ideally, opioids should be ceased if the goals of treatment are not being met.17
If stopping the opioid is difficult, aim to reduce to the lowest feasible dose while maintaining patient engagement.2, 3, 21, 25 After a period of stability reintroduce the idea of further slow dose reduction.
Also consider reducing the dose or stopping if the patient is experiencing opioid-related complications,16 or has deterioration in physical, emotional, or social functioning. Reducing a patient’s opioid dose can lessen potential harm whilst allowing patients to feel they have some control over their pain.
Reducing opioids is often challenging and how to best reduce the dose is not well understood.26 A general approach of gradually reducing the daily dose by 5-25% every 1-4 weeks is recommended by several deprescribing guides;21 the longer the patient has been taking an opioid, the slower the taper should be.11
Increasingly researchers are exploring neuroplasticity in persistent pain and the potential for brain retraining to enable recovery from pain. Randomised controlled trial (RCT) evidence is now emerging supporting the use of brain retraining tools in clinical practice.
Brain retraining is undertaken within the context of pain neuroscience education that assists in understanding the relationship between our brains and the pain response. Pain neuroscience education explains the biological processes that underpin pain, aiming to shift a person’s understanding of their pain from that of a marker of tissue damage or disease, to that of a marker of the perceived need to protect body tissue.27, 28 It also helps people understand the negative role that hypervigilance,29 pain catastrophising30, 31, 32 and fear avoidance30, 33 play in recovering from pain (see diagram 1: Breaking the Pain Cycle).
Multiple therapeutic approaches used for persistent pain can be conceptualised as techniques of brain retraining. Alongside pain neuroscience education, brain retraining tools that have been studied include:
Cognitive behavioural therapy (CBT) assists with changing negative thoughts and distressing emotions. A Cochrane systematic review involving 75 studies found a small positive effect for reduction in pain, disability and distress.34
Mindfulness has been shown to assist with pain management. A systematic review of 38 RCTs found using mindfulness meditation resulted in a small reduction in pain, as well as reduced symptoms of depression and improved quality of life.35
Acceptance and commitment therapy (ACT) assists people to improve their psychological flexibility using mindfulness, cognitive defusion techniques and acceptance skills, as well as self-observation, and actions consistent with values. RCTs involving eleven studies of ACT with people with chronic pain, have shown improvements in pain acceptance and small improvements in function.36
Graded exposure therapy addresses fear avoidance by gradually introducing situations that encourage individuals to try manageable activities, increasing their confidence with each success. RCT evidence from two studies in patients with low back pain shows this approach can reduce disability and catastrophising compared to graded activity.37
Graded motor imagery involves people with pain visualising doing movements without pain or observing others safely doing the movements. The principle underpinning this technique is activation of the brain’s mirror neurons to assist brain retraining so individuals learn a movement can be experienced without pain. RCT evidence from two studies shows this technique can be effective for reducing pain.38
Although the brain retraining tools described above have all been associated with positive outcomes when used alone, researchers have usually concluded that the effects are small. Recent trials testing the combination of brain retraining strategies, highlight the potential for recovery from pain when these techniques are used in combination.
In 2021, two small randomised controlled trials were published suggesting multi-component therapy may be the best approach. One in 151 participants9 and the other in 35 participants39 tested a multi-component strategy comprising of at least four elements; pain neuroscience education, graded exposure or imagery, cognitive therapy and emotional regulation or stress reduction therapy. While small, both trials showed outcomes with more than 50% of participants pain free or near pain free at 6 months.
While the evidence is still emerging for brain retraining therapies, multi-component strategies may represent the best option for consideration for your veteran patients who are engaged and interested in pain recovery. There was some variation between the two trials in which components were used. It is recognised that a one size fits all approach is not successful in pain treatment40 and thus, it is likely that the combination of strategies in a multi-component approach needs to be tailored to the individual needs of each veteran.