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Chronic Pain

Pain management: pacing and goal setting

Chronic pain can change the way that people live their lives and carry out their daily activities. For example many people found that they could no longer perform certain tasks without experiencing increased pain and fatigue. This could lead to them becoming increasingly inactive, or catching up on jobs when they had a good day, which then lead to a flare-up of pain and the need to rest up for a few days (see also 'Coping with flare-up').

Many of the people that we talked to had learnt techniques to manage their activities, minimise their pain and help prevent flare-ups. Usually these techniques had been learnt on NHS Pain Management Programmes through healthcare professionals, or support groups, but others had learnt through the Internet or books (see also 'Learning about pain management'; 'NHS pain management programmes').

People learned to pace their jobs by breaking them down into smaller more manageable tasks. Many found it was important to learn their limitations. One man explained that it is useful to work out the length of time that you can do something before it gets painful and then take 20% off this time so that you stop before the pain “kicks in”. This is called 'setting a baseline'.

 

Explains how to work out a baseline of how long you can do something for before the pain increases.

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Age at interview: 49
Sex: Male
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Now, how to set a baseline is probably the point where you all start from. In other words, how long, you need to find out first, how long you can sit for, how long you can stand for, how long you can walk for. And let's say, for example, right you say 'Well I can sit here for twenty minutes and then the pain will increase' right? So, the sensible thing about it is to get up and move around before the pain increases. So, to enable you to do that, you need to shave off 20% of twenty minutes, which is three minutes, I think.  

That is your new baseline so that, I don't know, I'm not a mathematician, let's say it's twenty minutes your baseline and it's 10% off of that is three minutes, so you'll get up and walk around at seventeen minutes. It's as simple as that. So in other words, what you're doing is you're managing your pain, rather than the pain managing you.  

What we tend to do, people with pain, is when the pain increases we'll get up, or if we're walking along, when the pain increases or starts then we'll stop. So we'll use the pain as a measurement of when to stop, stand, sit. So setting your baselines, find out how long you can sit for, stand and walk, whatever that time is shave 20% off of that and that is your new baseline. Now when you start to stretch and exercise, you can increase your baselines by, if you want to, do it really gradually, do it a minute a week, do it a minute a day. You're in charge. 

Some found it helpful to leave post-it notes around the house, or set a timer to remind them to stop. Stopping to have a rest, do another activity, stretch or change position could all help. The length of time that they could do each activity was not set and could be gradually increased. However, during a flare-up of pain it was sometimes necessary to reduce the time and gradually build it up again as pain subsided.

 

Paces herself by prioritising when she is going to walk and when she is sitting uses a buzzer to...

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Age at interview: 29
Sex: Female
Age at diagnosis: 23
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Yes, say if I pace my walking, if I can walk round the house reasonably, but if I'm going to go out I know I can probably only go out and walk once during the day, I can either walk down to our local shops and back or I can go into town and walk once round a shop there or I can go out in the evening and go to a few pubs in town, so I can only do one of them, so you've got to pace yourself by choosing which one you want to fit your energy into and accept that once you've done one you probably won't be able to do the other. 

So that's one way of pacing, its like choosing what you're going to be doing throughout the day, and also if for example I'm working on my computer, I'm supposed to have a break whenever I start feeling really stiff and sore and you often keep working until you're in so much pain you can't move, so its good to have a sort of buzzer just to buzz you every half hour so you actually stop and get up and stretch and move around so that you can pace yourself to keep going at bit longer by stopping at regular intervals to actually relax and take a break, because I know I get so absorbed in what I'm doing that you don't notice then pain until its so bad and then you're stuffed for the rest of the day which doesn't help.

 

Has learnt to gradually increase the length of time that she can walk the dog.

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Age at interview: 48
Sex: Female
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Well I used to walk miles and miles with the dogs and it came that I couldn't and was not really walking them at all. I'd bundle them in the car. I was frightened of injuring myself again which might have happened, might not have done, odds were that it wouldn't have done, so I started out just doing 5 minutes with the dogs and building up from there. So that I could do that more often and now I can walk for much longer periods of time with the dogs. 

Another example is fairly allied to that, I was saying at any other time I wouldn't walk any more than 10 minutes before stopping. I thought well, I don't need that, I'm not that bad, but it turned out that yes I did need that, that sort of discipline because I was feeling my back sore and stiffening in my neck was sore, I worked on that. 

So again I'd sometimes forget, but it's useful when I do remember to just... I mean you don't have to be overt about pausing but you can pause for a little while and then carry on again and carry on for quite a long time. So I think there's two quite sort of useful ones that I learnt and I wasn't particularly keen to learn them in the first place.

Pacing could be applied to all activities from preparing a meal to decorating a room, building or office work. Some found that a job that they used to do in a day had to be spread over a number of days or weeks but found satisfaction in being able to complete a job without increasing their pain.

One man gave the example of cutting his grass over two or more days. However, he would save jobs which needed to be done in one go for a 'good day'.

 

Finds he can achieve jobs by doing them over a few days but saves jobs that need to be done in...

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Age at interview: 56
Sex: Male
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Well I'm getting quite an expert in pacing because I was the worlds worst at pacing. That's basically if anything, if any jobs or tasks that you're fit to do, whether it be washing a cup or papering a wall you've got to get and learn your limitations, because the harder you're working and the longer you work it brings on your tension, stress, it brings on your pain, because you've over done your limits and its knowing and learning your limits through pacing. 

For instance if you were to cut your grass at the front and then cut you're grass at the back, if you cut the grass at the front one day and cut the grass at the back the second day, which is, that's pacing yourself, you still get that done. 

But you might find if you try and cut the front and the back the same day you can't do it, so then you start getting annoyed, stress, tension, all flares up, you get annoyed with yourself and you can't do that job, but if you can learn by doing half the job or even a quarter of the job and do it over the different days, you can sit back and say well I've done that job, okay it took me two days or three days but if you try to do it in the one day, you might not get the job done and land up in bed suffering chronic pain for 2 or 3 days being miserable.  

So by pacing yourself it still gives you that wee bit of dignity that well I've done that job I didn't need anybody to do that, what's the difference if it takes you two days, three days, is not better than as doing the job and not finishing the job and then ending up in bed with chronic pain, I took a long, long while to understand that and I purposely used to come home and try it and it wasn't for me, but I did manage it and it worked.

I still have the off days that again it comes into, I tend to use the word choice a lot, its my choice, if I know what its doing to me, but there's sometimes you just, if you start something you've got to finish it, I mean if you paint a door you can't paint half a door and then go back and paint the other half because it would show, so if you've got a good day you come down and paint that door you know you're going to have your chronic pain, the levels going to go up, but then its your choice, you know. But I think you've got to learn between what you really have to do and a lot of things that you don't have to do, and you can do it over 2 or 3 days. 

Prioritising the jobs that really needed to be done was an important part of pacing. A few people had learned to recognise feelings that they pushed themselves over the limit by telling themselves that they “ought to” or “should do” a job and realised that it was not the end of the world if something did not get done.

 

Feels it is important to prioritise important jobs and accept that it is not the end of the world...

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Age at interview: 47
Sex: Female
Age at diagnosis: 46
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Well, I think one of the main aspects of pacing is realising to stop doing something that you're doing before your pain really kicks in, you know maybe if you've got, say, four or five things that have to be done. Put them into sort of order of importance, you know. Really have to do that, that doesn't matter so much, you know at the very end and then maybe spend 10/15 minutes on doing something, have a break for about 5 minutes or something by either doing something else, especially if something you're doing was repetitive and you maybe just moving your hand all the time or something like that, like cleaning windows or ironing, you know the woman said at the course that I went on. 

So before you feel it really kicking in, stop and you know, have a rest, do your like deep breathing exercises or stretches, you know exercise, just stretches, even sitting in a chair can help and then maybe move on and you know, try and get it into your mind that the world's not going to come to an end if X, Y, Z doesn't get done and move onto something else and just kind of take it from there. 

It's getting to recognise before the actual pain kicks in and gets worse. It's difficult to recognise it if you have been so used to going about just doing things you know and then you go onto something else. Some people don't realise just how exhausted they actually are and if you're in any kind of pain obviously it makes it a lot worse. It's just recognising it and stopping it before you make it worse you know, because that can make the rest of your day worse and the following day as well. 

Whereas if you learn to pace yourself you're maybe not so as exhausted and sore at the end of the day and the next day you're kind of starting from the same level rather than 'Oh I feel even worse than yesterday'. It takes, it takes a while to kind of get your head around it though but it can be helpful. I don't always remember, I must admit but I do sort of, I'm more aware of it now than I was before I went to the Pain Association thing because I just wasn't aware of anything like that before.

A woman who had always prided herself on completing all of her housework by mid-morning recognised that it was okay to lower her standards. Most recognised that it was better to pace an activity than end up with increased pain.

 

Feels he is not a natural pacer but knows that it is better to pace than end up in pain.

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Age at interview: 61
Sex: Male
Age at diagnosis: 50
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My big problem is that I'm not a natural pacer. I'm an impatient fellow and I like to get things done. I'm also a very energetic person and so again I charge ahead and do it and the worst problem with chronic pain is the consequences of overdoing things and so for example I might decide in the garden that I'm going to build a fence. Well in the old days I would have done it in one twelve hour stint, now I have to make it last ten days in spite of my desire to get the job done and so my natural inclination is fighting against pacing but my intelligence is telling me for God's sake pace.

I'll explain. Just the fence for example. If you put up a fence you have to concrete in posts. Well mixing concrete with a bad back is an extremely painful business because you're using a shovel and you're mixing sand and cement and water, achieving a certain consistency, putting it in a bucket, putting it in a hole and all the rest of it. All requires a lot of bending. And you, you're faced with a choice. You've got to put up four fenced posts, you want to get the job done. 

And the smart advice is to do one post a day and then do something for the rest of the day. Your inclination is to do the concreting which is a messy job that you want to get out of the way anyway, is to do the concreting and all at one fell swoop and you sometimes have to balance your desire to get the job finished and your awareness that finishing it in one go is going to raise your pain level. And sometimes you just have, you have to calculate. 

You make a, you know, you just make a calculation I'm going to get away with this. Sometimes you do and sometimes you don't and sometimes the pain gets so fierce you have to pack it in halfway through anyway. So probably on all accounts you're better off to pace from the word go and just learn the new way of doing things.

Pacing did not come naturally to some people, who feel frustrated not to be able to complete tasks as they used to. Others felt that it was important to push the boundaries and occasionally overdid things. Although this could result in a flare-up of pain they decided it was worth it for something specific and sometimes planned time to deal with the flare-up.

Setting short and long-term goals is important for many people. One man explained that he set himself small daily goals, for example walking round the garden or meeting his wife from work. Several people had set themselves goals, which required them to be more active and that they had had to gradually work up to.

 

Feels it is important for him set and achieve small goals each day.

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Age at interview: 57
Sex: Male
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Well goal setting is another thing. To set yourself a goal that each day you get up and try and go for a walk, or try and just go out in the garden. Its all about... I think its all about getting your mind occupied, to set yourself a goal. And that when you do it, pat yourself on the back, give yourself a wee treat or whatever. 

But each day that you get up just set yourself a wee target, like I'll try and walk, I'll try and walk up and meet my wife just coming out of her work, or try and go up to the Co-op and get messages. Different wee things like that, that won't mean much to other people but to me its another target that I've set myself and its another goal, which I have achieved. 

These ranged from aiming to sit in a normal chair, to getting back on a bicycle, or even climbing a small mountain. Another person described increasing her exercise to achieve her goal of going on safari.

 

While he was at the pain management programme he set, worked towards and achieved his goal of...

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Age at interview: 61
Sex: Male
Age at diagnosis: 50
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After about, well you went home every weekend and after a week of just, one week of this gentle exercise I found that I could stand up out of a chair which was something I hadn't done for several years. You know on an ordinary straight back chair I could just stand up. I'd never been able to, you know, I've always had to haul myself up or get help up and hadn't been able to do it, and after just one week of this exercise and education I was able to stand up out of a straight chair. You know, at a dinner table whatever. 

So I was completely astonished but I had been so sceptical that all the staff thought I wasn't going to come back. They thought I was going to quit in the first week. You know I always had this perpetual frown on my face and was questioning everything and you know like, 'I don't think this is going to work'. But just that one piece of proof and so in the second week I threw myself into it much more wholeheartedly and in the second week on the Monday or the Tuesday the occupational therapist said 'Right. I want you to set a goal for yourselves. A physical goal' You know, I'm just going to carry on okay. 

And I looked out the window and saw south of the clinic was this mountain and I said 'I'm going to climb that mountain' The physiotherapist said 'Look, wait a minute. You can do that in six months. You don't have to do it on the course. If you feel that confident that you'll get that far, you know, just something for the course.' And I said to her 'You know I used to be a mountain walker and that's what I'd like to try and do.' And she said 'Seriously. Just going to the supermarket would be enough. You don't have to do anything dramatic.' 

But I'm a pig-headed individual. And having decided that was what I was going to do. I got even more into the exercises and stuff and started to do little walks. And I hadn't walked willingly without crutches a foot for four or five years. And I got some binoculars and I went and reconnoitred the thing and found that, that there was a way up it. I, with binoculars, I planned the route because one of the great things they teach in pain management is called pacing and you, instead of' 

We'll use a mountain as an example, instead of going straight to the top of the mountain you go in little stages and by looking at it I could see that I could go maybe 50 yards and there was a place to rest and then I'd go another 50 yards and another place to rest and so I figured that I could pace my way up the mountain. And I mean I say mountain, it's a Welsh mountain, it's not Everest, it's 2,009 feet high. But it sticks up out of the plain and it's a very dramatic hill and it's beautiful. 

Anyway, I did a little, just to test myself. I started doing a little bit of hill walking and I'd just go you know quarter of a mile and I found I could do it. And because of the various techniques that they'd taught us, you know, if the pain gets severe have an escape route figured out. Have a plan of action that you are going to do if you can't make what, you know, some place to rest up. You know, figure it out as you go along so that you are not going to just suddenly collapse in agony and not being able to get out of there. 

So it's all, pain management is very, very practical. Things like pacing, you know it's obvious when you think about it but people don't think about when they are in pain. But you can achieve an enormous amount if you break it down into little stages. So I figured it out and after you know, cut a long story short, after three and a half weeks and having done a couple of preliminary shorter climbs to make sure that it was at least feasible, I did it. I got to the top.
 

Worked on increasing her fitness so she could achieve her goal of going on a camping safari holiday.

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Age at interview: 27
Sex: Female
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But its all about goals, another goal of mine was last year when I was at, one of my goals in my rehabilitation was to be able to go on a camping safari when I went to South Africa on a visit and we went to the Oka-vango Delta. 

We only did three days and we camped, so I had a little blow up mattress that they provided, but it was quite thin, and I was walking two hours in the morning and two hours in the evening tracking animals, something I didn't think I would be able to do for a lot longer, that was my goal at the stage, and my next goal was then the skiing and riding a bicycle things that I didn't think I could do again, but... 

So for three days I managed to sleep in a tent on the floor in a sleeping bag. And I won't say I didn't have any pain that would be a complete lie, but it was, I was able to manage my pain on the trip and I managed to track animals on foot, which was quite an experience. So its just moving on from goals, goal to goal.

How did you work up to that goal?

Just exercising and practising the exercises that my physiotherapist had given me, I have fitness balls which I do some things, and it was also mentally preparing myself, learning to manage my pain. 

Learning to recognise when my pain, instead of feeling the pain when it was excruciating, learning to recognise the slight signal that was going to say you're going to be in pain in an hour or twos time, so slow down and that will decrease the pain. 

I was, and that is something, and when we were on the walking tour, it was just the two of us with one guide, so I wasn't having to keep up with other people, which was very important to me, because I always feel if I'm in a group I need to keep up with people, and I don't want to tell them my whole story and say, you know please just understand.

A man explained that an important part of achieving a goal was problem solving and asking others how they did things.

 

Explains that part of achieving a goal is problem solving which can involve asking others how...

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Age at interview: 49
Sex: Male
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So goal setting is increasing things, you know, how can I increase things? But you've got to do it in a gradual way. Thinking about, not only just thinking how you're going to increase your stretching and exercising, increasing your baselines, just think about looking at ways on how you're going to return to work through your problem solving.  

Okay the problem solving method is this, is that 'Okay, what's your problem?'  'I want to go to the movies'. Right that's my problem. Right, lets sit down and list some ideas on ways on how I can go about getting myself to go and see a movie. 

Once you've got a list, chose one of those what, right this is the best way. Okay, I want to go to the movies okay, when I book up I want to book up the rear seat, so I can get up to stand at the back. Like a lot of people think they don't go to the movies because they, they've got to stand up every once in a while. Where if you book a seat right at the back, used to go when you was a courting couple, you can get up and stand. Because everybody's watching the screen, but you're right at the back. So that's one of the ideas.  

It might be perhaps go when there aren't so many people in the cinema. So, set yourself, give yourself a list, then chose one from that list, assess the results, try it out, go and see a movie, perhaps a short movie, sit at the back and you can stand up if you want to, so then assess the results.  'Did that work for me?'  If it didn't, then cross one of, another one out of your list and then assess the results from that. 

Another part of the pr', formula is, ask other people 'Eh, you know, you've been, you've got back problem, how do you, do you go and see the movies?  How do you go about it?'  You know, so you're asking others.

I think the most important one is the end one of the formula is accept that the problem may not be solvable now because of, you're not fit, it maybe that you may not be able to go and see a movie just yet, but you may be able to when you get fitter, you might be able to go and see them in a month or so's time. So it's like problem solving. We all get problems in life, but we've got to look at ways, we've got to move forward as well. 


Last reviewed August 2018.
 



 

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