SMART for Chronic Disabling Pain

The only scientifically validated strategy to help patients handle chronic pain without strong analgesic medication or surgery involves a cognitive behavioral counseling approach that focuses on developing strategies for negotiating with the pain.  I call this “Symptom Management and Rehabilitation Training” (SMART).

 At first, most patients who are experiencing chronic disabling pain are unable to imagine that anything but medicine or surgery can handle their pain and that they cannot become an agent of change where their pain is concerned, but that some medicine expert is necessary.  Well, I am an expert and I can tell you that you need to help yourself.  If we can get you to accept that you are able to participate in your pain management by being intentional about what you think, we can probably help you handle your pain! 

 There is strong scientific evidence for the relationship between how pain is experienced and how a patient thinks and handles stress.  There is a direct relationship between mind and body that we can take advantage of; what a patient thinks is directly related to how they experience pain. 

 The first question to ask a patient with severe chronic disabling pain, is, “What makes it worse?”  Listen carefully for the response that indicates that personal agency is lacking.  Ask yourself, “Is the patient in charge or is something else in charge?”  If the patient responds, “nothing, it’s always as bad as it can be”, you don’t have an opening for change because the patient is closed off to the possibility of personal agency.  Similarly, if the patient responds, “my medicine is the only thing that helps”, the patient has identified something over which they don’t have complete control.  This response greatly limits the possibilities of developing an attitude of personal agency, but does not close it off entirely.  Better responses to the question include any degree of activity-relatedness.  That is, if the patient says, “whenever I stand more than 15 minutes or walk more than 10 minutes on a concrete floor, or climb two flights of stairs, my pain gets much worse”, the stage has been set for teaching symptom negotiation.

 Symptom negotiation is just like it sounds.  SMART helps the patient learn to negotiate with their symptoms, neither giving in to them nor ignoring them.  The analogy I like to provide my clients is that of the Olympic champions in long-distance running.  Whenever Joan Benoit Samuelson started a race, she monitored her body symptoms over the first few miles.  A tight calf muscle or a pulse that was above the expected range immediately led to a change in her race tactics.  Her stride was lengthened or she would take on more water or change the depth of her breathing; anything to bring her body back to dependable symptoms.  Because she was the first female Olympic Marathon champion, she knew that she could not run her race optimally without dependable symptoms and she knew ahead of time that winning the race would require that she negotiate with her symptoms.

 The real champions do not ignore or avoid symptoms, they negotiate with them.  They push themselves hard to enough so that they become symptomatic; if not they’d never win a race.  But they don’t let the symptoms win; they do everything they can to adjust the symptoms, to negotiate with them.

 In SMART, symptom negotiation is easy to introduce, but can be somewhat difficult to integrate into everyday activities.  If the patient is involved in a therapy program that is dependably consistent day today, symptom negotiation can be much more easily learned.  There are two great examples of this.  The first is the work of Selvester and Rice and Ice and the early pioneers of cardiac rehabilitation.  The second is the work of Mooney and MacKenzie and Mayer and Gatchel and the early pioneers of spinal pain rehabilitation. 

 In the cardiac arena, helping a patient learn to use (and trust) angina pain as a “safety signal” is a very effective strategy to avoid “cardiac cripples”, patients who become so afraid of their anginal pain that they retire to the couch and gradually become irretrievably disabled.  Working with Dr. Ron Selvester and Dr. Harry Rice and physical therapist Randy Ice at Rancho Los Amigos Hospital, part of the University of Southern California, we taught patients that level 1 angina pain meant that their pain was just noticeable and nothing needed to be done.  At level 2, the patient was required to change the way they were working or walking or breathing.  Level 3 angina required the patient to do all this and to also use sub-lingual nitroglycerin.  At level 4, the patient was required to immediately ask for emergency help.  The psychological impact of this helped the patient to develop an attitude of personal agency; to control their symptoms, rather than to have their symptoms control them.  Imagine!  We were teaching people to pay attention to the symptom that told them their heart wasn’t getting enough blood!  What had previously been frightening became a useful symptom that made pain much more manageable.  Instead of being afraid of angina, the patient looked for it and accepted it at a particular level of activity and then adjusted their response according to the symptoms.  They learned to negotiate with their symptoms!  That’s SMART.

In the spinal pain arena, helping the patient to learn that most pain of this type has a dependable source and a relationship to posture and activity facilitated the development of effective alternatives to surgery for the control of disabling spinal pain.  Working with Dr. Vert Mooney at Rancho-USC, we developed pain diagrams and rating scales and invented the work hardening program, all of which were found to be very useful in educating patients about symptom negotiation.  Dr. Mooney brought physiotherapist Robin MacKenzie from New Zealand to educate Rancho staff and, eventually all spinal pain professionals in North America on the benefits of diagnosing and treating spinal pain from a mechanical perspective.  He would put a patient into postures carefully so that the pain was elicited, and then work with the patient to develop alternative postures and movement patterns. 

 The psychological impact of this perspective also is very positive, helping the patient to develop an attitude of personal agency based on posture and their participation in conditioning activities.  Dr. Mooney took these strategies to the University of Texas where he mentored Tom Mayer and Robert Gatchel, who developed the PRIDE program, where they invented work conditioning and the concept of the industrial athlete and continue to be the world’s foremost experts with chronic disabling spinal pain, demonstrating scientifically – validated success as an alternative to spinal surgery.

 What is the common thread among these approaches?  The patient must accept ongoing responsibility for pain.  In order to manage pain, the patient must develop an attitude of personal agency.  You can wish away pain or hope that you can be pain-free some day if you get the right medicine or surgery, but if you really do have chronic disabling pain, that is all in your past and you need to move on and get back to living by being intentional about the messages you give yourself.  How you thinks affects how you feel.  SMART focuses on helping you become more aware of these messages and how to tweak them so that you negotiate with your symptoms and can finish the race like a champion.

 Here is the caveat: When the pain patient has cognitive or emotional limitations due to a brain injury or serious psychiatric disorder, SMART is much more difficult.  Patients who have a combination of chronic pain and either brain injury or stroke are extremely difficult to work with due to their inability to develop an attitude of personal agency.  Similarly, patients who are severely depressed, who have problems with maintaining contact with reality, or who are intellectually impaired and have a difficult time with learning are less likely to be successful in developing personal pain control strategies.  Although some of these patients can be helped, the rehabilitation process is quite prolonged and the outcome is much less likely to be successful.

 On the other hand, patients who easily develop an attitude of personal responsibility are often quite easy to work with.  Many athletes, actors, dancers, police officers and firefighters, politicians, military service officers and armed forces personnel are quite successful in developing strategies for handling chronic pain.  In each of these occupational areas, these people experience pain, discomfort, and illness that they must push through no matter what is expected.  Each person entering the field is mentored in that regard.  For athletes and dancers, the mentoring often begins in childhood so that, if the person abandons a career in athletics or dance in adolescence or adulthood, the early experience puts them in an advantageous position with regard to chronic pain that is similar to adults who come from these careers.  It is always helpful to ask about a patient’s occupational background as we begin to address chronic pain.

 Specific SMART strategies for dealing with chronic pain will be presented in future blogs, given sufficient interest from readers.  In the meantime, look at Personal Prayer Relaxation and the Happy Hippocampus; both are helpful for what may ail you.