I’ve pondered this question for a very long time. The term ‘self management’ is vexed as it is, let alone me questioning what we mean by ‘pain self management’, but let’s start with the definition I intend to use. Self management, to me, is anything I can do myself to live my life alongside my fibromyalgia, or any other long-term health problem I have. It can be supported by others because I don’t live in splendid isolation, but the actions are things I do. They’re my choice.
When we expand the definition to include pain, this is where things get a little tricky. Pain self management almost implies that I’m managing my pain. I’m not, not really. My pain tends to do its thing all by itself, with some known influences on intensity – and many unknown. If I attempted to ‘manage’ my pain, I’d be inclined to do all the things I can to reduce my pain because ‘managing pain’ kinda implies this, right? And if I tried to reduce my pain I’d be in for a very boring and constrained kind of life.
If I dig a little more deeply into the idea of pain self management and consider why pain reduction might be thought of as The Goal, it strikes me that we might focus on this if we think of pain intensity as a singular experience. If pain intensity had consistent effects, like a correlation between intensity and other things, then I could kind of understand it. But this is where things get complicated.
In broad brush terms, yes, pain intensity and interference are somewhat correlated – for example, in an ecological momentary assessment study of the relationship between migraine pain intensity and pain interference by Thomas et al. (2016), pain intensity was a consistent predictor of pain interference on migraine headache days, but this was moderated by pain catastrophising (and we’ve talked about this term here) as well as headache management self efficacy. But just to confuse things, in another ecological momentary assessment study, this time in people with chronic low back pain (Page et al., 2022), pain intensity fluctuated but had little influence on psychosocial and healthcare use outcomes. And to confuse things even more, a large registry study of more than 40,000 people from the Swedish Quality Registry for Pain Rehabilitation (Gerdle et al., 2023) found that pain intensity had stronger effect on interference than on lack of life control, whereas psychological distress had stronger effect on lack of life control than on interference. If you’re wondering what pain interference is, it’s thought to comprise activity interference (walking, work, daily doing) and affective interference (mood, social relationships, sleep, joy in life) (Cleeland & Ryan, 1994).
So it’s a pretty complicated relationship, and some of the factors known to influence the relationship are exactly the kinds of things we work very hard to alter in pain management therapies. Things like self-efficacy (the confidence I can successfully achieve what I set out to achieve in this domain) and pain-related worrying (aka catastrophising), along with attention, low mood, social support and willingness to experience pain if it’s worth it (aka ‘acceptance’).
What do I mean by ‘singular experience’? I mean that throughout every day pain intensity changes, pain quality changes, the locations change, the meaning of my pain changes, the attention I pay to pain changes… Pain intensity on its own has limited relevance to my life even if there are times I groan as I get out of my chair, or I can’t bridge to roll over at night because ouch! my hip hurts. This is because I know these aches and pains don’t mean a whole lot in terms of me doing the things that matter to me. I’m not harming myself.
Back to pain self management. If pain intensity has an influence but tends to have a moderating influence rather than a direct 1:1 impact on what matters to me, then focusing on pain intensity as the thing to ‘manage’ isn’t going to give me what I want out of life. If I do the things I know will reduce my pain, what do I have to not do? And what might that mean to me? For example, if I don’t want to aggravate my cranky hip (no, it’s not OA, I have lovely cartilage thanks! but there’s something tendinous going on…) then I should stop crouching to pick up agates from the beach; stop boulder-hopping along the river while I fish for trout; stop squatting to pull weeds and lifting heavy bags of compost for my garden… No way, no how!
I’m almost deliberately doing things that rev my pain up – because I love fishing, gardening, rock-hounding (new hobby!) and they’re worth more than not having pain! Instead, I do the things, make room for the ouch afterwards, and box on.
The things I do to optimise my life in the present of pain include:
- knowing when to say when
- making allowances for being a bit slower on the days following a good fish along the Hurunui
- using ‘nudging into’ the range of movement that elicits pain; using mindfulness (present moment awareness) to be curious about what my pain actually feels like in the moment (more on this in future posts!)
- remembering and savouring the joy of doing the things that make my life wonderful and rich
- asking for help sometimes (such an independent person!)
- seeing my GP for an X-ray to identify whether my hip pain is OA
…and you know what? These look more like ‘life management’ than pain management – and while they’re all things I do, they’re also about the way I incorporate my social support and my activities to make the most of the opportunities I have.
How does this approach differ from managing diabetes? In diabetes management I AM focusing on maintaining my HbA1c. Doing this does make a difference to my health and especially organ damage. In pain? Trying to maintain pain intensity at a certain level only robs me of what is worthwhile, and life’s too short for that.
Life’s too short to let my pain dominate and be my guide. While my set point for experiencing pain is lower than other people, it does not mean I should tiptoe around it. Knowing that it’s not an indication of harm, and being OK to make room for it to dance around all by itself, means I can focus on what I love to do and what brings me richness.
Cleeland, C., & Ryan, K. (1994). Pain assessment: global use of the Brief Pain Inventory. Annals of the Academy of Medicine, Singapore, 23(2), 129-138.
Gerdle, B., Dragioti, E., Rivano Fischer, M., & Ringqvist, A. (2023). Pain intensity and psychological distress show different associations with interference and lack of life control: A clinical registry-based cohort study of >40,000 chronic pain patients from SQRP. Front Pain Res (Lausanne), 4, 1093002. https://doi.org/10.3389/fpain.2023.1093002
Page, M. G., Gauvin, L., Sylvestre, M. P., Nitulescu, R., Dyachenko, A., & Choiniere, M. (2022). An Ecological Momentary Assessment Study of Pain Intensity Variability: Ascertaining Extent, Predictors, and Associations With Quality of Life, Interference and Health Care Utilization Among Individuals Living With Chronic Low Back Pain. J Pain, 23(7), 1151-1166. https://doi.org/10.1016/j.jpain.2022.01.001
Thomas, J.G., Pavlović, J.M., Lipton, R., Roth, J.L., Rathier, L., O’Leary, K.C., Buse, D.C., Evans, E., & Bond, D. (2016). Ecological momentary assessment of the relationship between headache pain intensity and pain interference in women with migraine and obesity. Cephalalgia, 36, 1228 – 1237.