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Transcript – Programme 14: Recent Developments in Nerve Pain and How to Get a Good Night’s Rest

What is a spinal cord stim­u­la­tor and could it help you to man­age your pain? Plus, com­plex region­al pain syn­drome, mir­ror ther­a­py for phan­tom limbs, and how chron­ic pain affects and is affect­ed by sleep

To lis­ten to this pro­gramme, please click here.

Paul Evans meets Edith Mowatt who has nerve root pain and hears how she has learned to man­age her con­di­tion and about her expe­ri­ence of spinal cord stim­u­la­tion. We hear a doctor’s view on these machines from Dr Steve Gilbert, and how they can also be used to treat com­plex region­al pain syn­drome. Dr Can­dy McCabe tells us more about this con­di­tion, as well as the use of mir­rors in ther­a­py for phan­tom limb pains.

Final­ly, Pro­fes­sor Mark Bla­grove and Dr Nicole Tang explain how pain affects sleep, and how a good night’s rest with the help of cog­ni­tive behav­iour­al ther­a­py can ease pain symptoms.

Issues cov­ered in this pro­gramme include: CPRS, com­plex region­al pain syn­drome, nerve root pain, insom­nia, phan­tom limb pain, mir­ror ther­a­py, CBT, cog­ni­tive behav­iour­al ther­a­py, NRS, non-recu­per­a­tive sleep, sci­at­i­ca, spinal cord stim­u­la­tor, frac­ture pain and visualisation.

Paul Evans: Hel­lo and wel­come to Air­ing Pain, a pro­gramme brought to you by Pain Con­cern. A UK Char­i­ty that pro­vides infor­ma­tion and sup­port for those of us who live with pain. Pain Con­cern was award­ed first prize in the 2009 NAP Awards in Chron­ic Pain and, with addi­tion­al fund­ing from the Big Lot­tery Fund’s Awards For All pro­gramme and the Vol­un­tary Action Fund com­mu­ni­ty chest, this has enabled us to make these programmes.

I’m Paul Evans and in today’s programme:

Mark Bla­grove: It is start­ing to be realised that insom­nia can have, not just have the inabil­i­ty to fall asleep, the impos­si­bil­i­ty of being asleep, but what is called ‘NRS’ or ‘Non Recu­per­a­tive Sleep’. So peo­ple can be asleep, but it not do them very much good.

Edith Mowatt: It kind of colours your whole life but you begin to learn to con­trol it and not let it con­trol you.

Can­dy McCabe: It sounds very strange to talk about mir­rors in rela­tion to a pain that is so great that it can’t be relieved by some tra­di­tion­al painkillers and that seems some­what bizarre and wacky.

Evans: More on those sub­jects lat­er. But we will start with one person’s sto­ry of how she copes with chron­ic pain. Edith Mowatt has nerve root pain and that is where the root of the nerve com­ing out from the spinal cord is irri­tat­ed, pressed on or dam­aged. And those with it feel the pain along the course of that nerve, say, down the leg, even as far as the foot where the pain is often worse than at its root in the back. Some peo­ple know this as ‘sci­at­i­ca’, but it can range in sever­i­ty from mild or as in Edith Mowatt’s case, excruciating.

Mowatt: If I could describe it in a sound, it would be like a con­tin­u­ous high-pitched scream which radi­at­ed from the base of my spine right down to my feet. I fell at home, I fell over my own feet and twist­ed as I fell, dam­ag­ing the discs in my spine. I was an offi­cer in charge of a home for the elder­ly at the time and I worked on with it for about four months until I realised that there was some­thing seri­ous­ly wrong. I saw my GP and I was in the hos­pi­tal the next day and that was the end of my career.

Evans: We’ll hear more about how Edith copes with her nerve root pain at the end of this pro­gramme. But you will know by now that one of our aims on Air­ing Pain is to put ques­tions you’ve raised with us to our pan­el of experts. One lis­ten­er has asked, ‘What’s a spinal cord stim­u­la­tor? How can it help peo­ple in pain and can you get one on the NHS [Nation­al Health Ser­vice]?’ Well hav­ing being fit­ted with one of these devices, Edith is in the per­fect posi­tion to explain the patients’ view­point and fol­low­ing her, Dr Steve Gilbert of Queen Mar­garet Hos­pi­tal in Fife will explain more.

Mowatt: A Spinal Stim­u­la­tor is a machine a bit like a TENS machine, except it’s implant­ed in me. The elec­trodes go either side of my spinal cord and the machine is just by my side where I have access and I switch myself on and off. It is easy to work but it takes a long time to get used to it.

Steve Gilbert: A spinal cord stim­u­la­tor is a machine that is a bit like a pace­mak­er which deliv­ers an elec­tri­cal cur­rent to the back of the spinal cord. You’ve prob­a­bly heard of a TENS machine which is an elec­tri­cal stim­u­la­tor, where you stick pads on the skin over the painful areas, some­times your back or your shoul­der or your knee, and it inter­feres with the pain trans­mis­sion by acti­vat­ing the pain gate. That means it’s using the same nerves, send­ing mes­sages in and muck­ing up the pain trans­mis­sion at the spinal cord lev­el, so that you feel less pain.

The spinal cord stim­u­la­tor works in a slight­ly dif­fer­ent way – we are not real­ly exact­ly sure what the under­ly­ing mech­a­nism is – but we have found that, by deliv­er­ing a low cur­rent to the back of the spinal cord, which is where the nerves all come down inside your spine (so it has to be insert­ed through a nee­dle or a small oper­a­tion into that area) – it can give you pins and nee­dles or a numb sen­sa­tion in the area where you would feel the pain. It doesn’t make the feel­ing go back to nor­mal, it replaces the painful sen­sa­tion with the pins and nee­dles or this, what we call, ‘para-seizure sensation’.

It has been found to be real­ly help­ful for some peo­ple with per­sis­tent nerve pain and some peo­ple also with com­plex region­al pain syn­drome, which is where every­thing becomes very sen­si­tive in a hand or a foot. It’s also been found to be help­ful for some con­di­tions, such as angi­na, where you have pain com­ing from the blood ves­sels around your heart, but they can’t do an oper­a­tion that can improve the blood sup­ply. And the inter­est­ing thing about the spinal cord stim­u­la­tor is that actu­al­ly it does increase the sup­ply of blood and oxy­gen deliv­ery into the tissues.

Now, spinal cord stim­u­la­tors are only done in spe­cial­ist cen­tres and so you have to ask your doc­tor can I be referred for assess­ment for a spinal cord stim­u­la­tor. Often the doc­tor you will see, even if they are in a spe­cial­ist pain clin­ic, might not have expe­ri­ence them­selves of spinal cord stim­u­la­tors and might not know whether it’s exact­ly the right thing for you. This is pos­si­ble on the NHS and it is a slight­ly com­pli­cat­ed route that you have to go through to get the fund­ing for it. Now the spinal cord stim­u­la­tion is real­ly quite an expen­sive treat­ment but I don’t think that this should nec­es­sar­i­ly stop us explor­ing this as an avenue of treat­ment if it’s going to sig­nif­i­cant­ly improve your pain and qual­i­ty of life. But I’ve got to empha­sise that there are only a few peo­ple that will actu­al­ly ben­e­fit from a spinal cord stimulator.

Evans: Dr Steve Gilbert of Queen Mar­garet Hos­pi­tal in Fife.

And please do send us your ques­tions via any of the usu­al routes which you can find at our web­site which is painconcern.org.uk. But let me just remind you that whilst we believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound based on the best judge­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well­be­ing. He or she is the only per­son who knows you and your cir­cum­stances and there­fore the appro­pri­ate action to take on your behalf.

Dr Steve Gilbert men­tioned com­plex region­al pain syn­drome – now this is a con­di­tion that we know very lit­tle about and seem to be poor at diag­nos­ing. But we do know what improves the symp­toms and what makes them worse. Can­dy McCabe is Pro­fes­sor in Nurs­ing and Pain Sci­ences at the Uni­ver­si­ty of West Eng­land. She’s also a con­sul­tant nurse.

Can­dy McCabe: The most com­mon way that peo­ple are first aware of com­plex region­al pain syn­drome is if they have a fair­ly sim­ple frac­ture, like a frac­ture of a wrist, and the first thing that they tend to be aware of is that the pain is utter­ly dif­fer­ent to any sort of pain that they have ever had before. It seems more than you would expect for a frac­ture, even though you’ve nev­er had a frac­ture, peo­ple com­mon­ly report that they’re very sur­prised by the lev­el of pain.

The oth­er first com­mon pre­sen­ta­tion is that if they’re wear­ing a plas­ter cast for that frac­ture, they feel as if that plas­ter cast is far too tight and they’re con­stant­ly going back to the doc­tor say­ing, ‘My arm is swollen. The cast is too tight. I need the cast chang­ing.’ And, in fact, when it’s looked at by the doc­tor, by the plas­ter tech­ni­cian, they can see that it’s a per­fect fit and there’s no prob­lem with it.

Then, six weeks lat­er when the plas­ter cast is removed patients may be shocked to find that they have a very dis­coloured look­ing limb. Now it’s com­mon after a plas­ter cast com­ing off that the limb looks a bit dif­fer­ent, but with CRPS peo­ple find that the limb may look very blue or red; they may feel like it’s very hot or intense­ly cold; they may find that the skin is very shiny, sweaty and there could be a dra­mat­ic increase in the hair growth that’s on that limb so they may find actu­al­ly that they’ve got very thick black hair grow­ing on that limb and their nails have grown phe­nom­e­nal­ly. The limb is com­mon­ly swollen and, again, it’s the pain that is the biggest prob­lem to peo­ple with this con­di­tion. They don’t want to touch the limb, they don’t want any­body else to touch it and quite quick­ly they feel that the limb doesn’t belong to them and com­mon­ly, with­in a mat­ter of days or even weeks, they feel like they would like that limb cut off. It feels alien to them – they don’t wish to be con­nect­ed to that limb any longer.

We don’t real­ly know what caus­es it, but most com­mon­ly peo­ple will present fol­low­ing a frac­ture or a num­ber of repeat sur­gi­cal inter­ven­tions into a limb. The oth­er thing that can trig­ger it is pro­longed cast­ing, so if peo­ple have had com­plex surgery that’s required them to be in a cast for a num­ber of months, then that can be a risk fac­tor for devel­op­ing CRPS. But also you can just wake up in the morn­ing and have spon­ta­neous onset symp­toms in the limb which is even more con­fus­ing because you’re des­per­ate­ly try­ing to think of what caused it, how did it hap­pen and there may be no obvi­ous trig­ger at all. But the most com­mon things are trau­ma, surgery and pro­longed plas­ter casting.

There are three approach­es to the treat­ment. The first is to deal some­how with that pain, so you would be giv­en a range of dif­fer­ent med­ica­tions to help relieve that pain. And that may range from very sim­ple painkillers up to more com­plex pain reliev­ers depend­ing on your lev­el of pain. The next arm in these three treat­ments is to have some psy­cho­log­i­cal sup­port, because it’s very dis­tress­ing. Pain of any sort can impact on your life, it affects your fam­i­ly, your job, so some psy­cho­log­i­cal sup­port is real­ly important.

But the pri­ma­ry treat­ment and the one that is there that is sup­port­ed by these oth­er two is phys­i­cal reha­bil­i­ta­tion. And that is the most impor­tant thing to start as ear­ly as pos­si­ble. So patients should use that limb as much as they can despite the fact that they don’t want to. Despite the fact they feel the pain is so great that they need to pro­tect it. Actu­al­ly, what they need to do is use it lit­tle and often. Touch it a lot – get the brain to recog­nise that limb again as their own.

Evans: Now, a brain that does not recog­nise a limb of its own is a strange con­cept to grasp. But some amputees expe­ri­ence a sim­i­lar but oppo­site feel­ing of a limb that was there but is no longer, the so called ‘phan­tom limb’. A treat­ment to cor­rect this involves the use of mir­rors and Can­dy McCabe has been exper­i­ment­ing with a sim­i­lar tech­nique for the treat­ment of com­plex region­al pain syndrome.

McCabe: It sounds very strange to talk about mir­rors in rela­tion to a pain that is so great that it can’t be relieved by some tra­di­tion­al painkillers and that seems some­what bizarre and wacky. But actu­al­ly mir­rors have been shown to be very use­ful in reliev­ing amputee phan­tom limb pain by trick­ing the brain into appar­ent­ly see­ing that the patient has got their limb back again. And we think what hap­pens in phan­tom limb pain is that the mech­a­nism that dri­ves the pain is a mis­match between what the brain is expect­ing to see in that limb and the infor­ma­tion that its get­ting back from the limb. So by giv­ing some­body a mir­ror to look in where they are tricked into see­ing two nor­mal limbs again – it gives the brain back what it wants to see.

And with com­plex region­al pain syn­drome we think a very sim­i­lar mech­a­nism is hap­pen­ing – that because you have reduced or changed infor­ma­tion com­ing back from the painful limb, the brain doesn’t recog­nise it as it should do; it strug­gles to plan move­ments through that limb and, because there’s a mis­match between what the brain expects to see and the infor­ma­tion com­ing back, it has to devel­op some sen­sa­tions to tell you that there’s a prob­lem. The sen­sa­tions that it devel­ops is this unpleas­ant pain, these sen­so­ry changes.

So the mir­ror is there to give good sen­so­ry feed­back – good infor­ma­tion back to the brain about what that limb actu­al­ly looks like, the fact that that limb can move. So patients will posi­tion a limb on the cen­tre of their bod­ies so they are able to look at a reflect­ed image of the unaf­fect­ed limb – look in the mir­ror and low and behold they have two nor­mal look­ing limbs just by look­ing at the reflec­tion of the unaf­fect­ed limb. And then you would be asked to move both limbs simul­ta­ne­ous­ly while look­ing at this reflect­ed image that is super­im­posed on the area of your affect­ed limb. And by doing this lit­tle and often we can start to repro­gram the brain so that it recog­nis­es a more nor­mal limb and there­fore no longer has to send out these alert mech­a­nisms to tell you that there is a painful limb and your pain improves, move­ment improves and the con­di­tion starts to resolve.

But what I would stress is that this isn’t a cure in its own right – it’s very impor­tant that you use the three treat­ment par­a­digms in CRPS, so you have med­ica­tion, psy­cho­log­i­cal sup­port, and phys­i­cal reha­bil­i­ta­tion. The mir­ror is anoth­er tool in the trick box – it’s anoth­er tool in your armoury to help cor­rect the brain path­ways, cor­rect the mes­sages and so we would nev­er use a mir­ror all on its own with­out these oth­er treat­ments but what we have found is that peo­ple with very ear­ly symp­toms – it can pro­vide instant pain relief as they look in the mir­ror – you remove the mir­ror and the pain returns. So we ask peo­ple to do it lit­tle and often – five or six times a day – no more than five min­utes at a time so that they can concentrate.

For those peo­ple fur­ther down in the treat­ment who may have had this con­di­tion for one year, three years – we find that it’s per­haps not as effec­tive but this varies between indi­vid­u­als. It’s also real­ly impor­tant that you’re assessed first of all by some­body who has been trained in this tech­nique, because it can increase your pain if not used cor­rect­ly. Train­ing more peo­ple into mir­ror image feed­back would be very help­ful but I think much more impor­tant­ly is train­ing peo­ple in recog­nis­ing the ear­ly symp­toms of com­plex region­al pain syn­drome. If peo­ple under­stand bet­ter the mech­a­nisms that dri­ve this con­di­tion, iden­ti­fy it more quick­ly, we can treat peo­ple more quick­ly and there­fore we would have few­er peo­ple going on to get the chron­ic symptoms.

Evans: Can­dy McCabe, Pro­fes­sor in Nurs­ing and Pain Sci­ences at the Uni­ver­si­ty of West Eng­land. This is Air­ing Pain with me, Paul Evans.

Now, poor inef­fec­tu­al sleep and chron­ic pain go hand in hand. Yet sleep is one of our basic needs. So what is sleep? Mark Bla­grove is Pro­fes­sor of Psy­chol­o­gy at Swansea University.

Mark Bla­grove: Sleep is a peri­od when you are usu­al­ly very still dur­ing the night and for mam­mals, includ­ing humans, it is made up of dif­fer­ent stages: light sleep, which is stages 1 and 2 and then deep sleep which is stage 3 and then there is also a rapid eye move­ment sleep which occurs every 90 min­utes. We are not sure why there are these dif­fer­ent stages and in fact they are quite intri­cate­ly arranged so that you alter­nate between deep sleep and REM sleep through­out the night with deep sleep pre­dom­i­nat­ing in the first half of the night. REM sleep pre­dom­i­nat­ing in the sec­ond half of the night and hav­ing light sleep between each instance of deep and REM sleep, so it’s actu­al­ly very complicated.

Evans: What do you mean by REM sleep?

Bla­grove: REM sleep is Rapid Eye Move­ment sleep in which the brain looks like, has many of the char­ac­ter­is­tics of being awake and has as many brain­waves that look as if you are awake but you are in fact com­plete­ly asleep and your eyes are mov­ing back­wards and for­wards quite frequently.

Evans: Do the dif­fer­ent stages of sleep, do they have dif­fer­ent func­tions through­out the night?

Bla­grove: They might do – no one’s quite sure yet, deep sleep may be involved in main­tain­ing our warm blood­ed­ness. Deep sleep and stage 2 sleep and REM sleep may all be involved in con­sol­i­dat­ing dif­fer­ent types of mem­o­ry and there’s the pos­si­bil­i­ty that we have oth­er hor­mone or neu­ro­trans­mit­ter func­tions going on – reset­ting them, for exam­ple, which are tied to dif­fer­ent parts of the night. So it could be a whole lot of dif­fer­ent func­tions for the dif­fer­ent stages.

Evans: Is there a rela­tion­ship between sleep and pain disorders?

Bla­grove: There is a rela­tion­ship between sleep and some pain dis­or­ders. What can hap­pen is that they can both inter­act with each oth­er, so obvi­ous­ly the pain can cause peo­ple to have a worse sleep. So espe­cial­ly the deep sleep and the REM sleep can become dimin­ished and you will be left with light sleep which is less recu­per­a­tive and so the pain can affect your sleep. There is the pos­si­bil­i­ty also of sleep affect­ing pain. One pos­si­bil­i­ty is that peo­ple seem to be more sen­si­tive to pain if they have not had enough sleep and so you can do stan­dard pain tests on peo­ple, for exam­ple, by putting their hands in very cold ice water, which is absolute­ly ter­ri­ble, and if peo­ple have been deprived of sleep, then the pain feels far worse. So that’s one way in which sleep can affect pain.

Evans: Let me just describe the sleep I had last night and I have most nights and which many peo­ple get. I feel that I’ve been awake in the night, I’ve obvi­ous­ly had a full night’s sleep because my wife has told me that I’ve been snor­ing, but I’ve wok­en up and I don’t feel rest­ed or healed in any way.

Bla­grove: Yes, it is start­ing to be realised that insom­nia can have, not just have the inabil­i­ty to fall asleep but the pos­si­bil­i­ty of being asleep but what is called ‘NRS’ or ‘non-recu­per­a­tive sleep’. So peo­ple can be asleep but it not do them very much good. Now one pos­si­bil­i­ty there is if you’ve had the light­est stages of sleep and just those and you haven’t gone into deep and REM sleep, you may have well have been asleep all night and you may just wake up and feel extreme­ly fatigued because the sleep has just been of the light type.

Now, although we are not quite sure about what it is that light sleep and what it is that deep sleep and REM sleep all do for us, it does seem to be that if you have a night full of light sleep, then peo­ple feel much worse than if they had the oth­er two types of sleep with it. So, although we don’t know what deep sleep and REM sleep do for us, if we lack them and just have light sleep, peo­ple can feel the difference.

Evans: That’s Mark Bla­grove, Pro­fes­sor of Psy­chol­o­gy at Swansea Uni­ver­si­ty. So what pro­por­tion of peo­ple with chron­ic pain do expe­ri­ence sleep prob­lems. Dr Nicole Tang is a research fel­low at the Insti­tute of Psychiatry.

Nicole Tang: Usu­al­ly you will hear per­cent­ages, like 90% of the peo­ple who go to a pain clin­ic to seek help they will report some kind of sleep prob­lem. One of my stud­ies… we have used a stan­dard­ised insom­nia scale to check the preva­lence and sever­i­ty of clin­i­cal insom­nia in that pop­u­la­tion. We found that actu­al­ly, more than half the peo­ple going to a pain clin­ic will suf­fer from some kind of clin­i­cal insom­nia of either mod­er­ate or severe level.

When you have insom­nia and chron­ic pain, it real­ly mess­es up the prob­lem quite a lot because when you have the pain, the first thing that you want to do is to per­haps not think about the pain and when you been hav­ing it all day, you real­ly just want to have a time when you don’t feel the pain, when you’re not con­scious of the pain, so that you can have a respite. So for a lot of peo­ple with chron­ic pain will some­times use sleep as an escape, but when they’re so des­per­ate to get an escape they actu­al­ly spend a lot of time in bed and that is not the way to reg­u­late the sleep. So when you’re try­ing so hard to get to sleep, for­get the pain, you’re actu­al­ly vio­lat­ing some very essen­tial rules – how to get a good night’s sleep – because by extend­ing your time in bed, you’re just increas­ing your frus­tra­tion that you are not going to get some sleep because you can’t expect your body to sleep, let’s say, 12 hours a day.

Evans: Now, Nic­hole Tang uses a num­ber of cog­ni­tive behav­iour­al process­es in help­ing peo­ple with their sleep prob­lems. You may remem­ber that cog­ni­tive behav­iour­al ther­a­py, CBT, helps man­age our prob­lems by chang­ing how we think and how we act.

Tang: Some­times peo­ple think that the more sleep I get, the bet­ter it will be for my pain. That’s actu­al­ly not the case. When we’ve been look­ing into the research find­ings or the treat­ment find­ings, when peo­ple are say­ing, ‘I’m now feel­ing bet­ter’, it’s not nec­es­sar­i­ly because they’re get­ting more sleep, but poten­tial­ly because they’re get­ting a high­er qual­i­ty of sleep with­in a short­er peri­od of time.

And the aim of using CBT a lot of the time is not about con­trol­ling sleep or con­trol­ling pain, it is more about help­ing peo­ple to under­stand how pain and sleep work and then so that they can find a dif­fer­ent per­spec­tive of what is going on with them. Because a lot of the time when they have psy­cho­log­i­cal prob­lems it’s main­ly stem­ming from the frus­tra­tion of not know­ing how to con­trol the prob­lem. So to con­trol they’ll use their own strat­e­gy. But a lot of the time those strate­gies are not very well thought out and it is based on a lot of limitations.

So what we help them to do is to take a step back to recon­sid­er their sit­u­a­tion so that they can have a broad­er view to see what the options are. And then when they take a step back being calmer know­ing what are the options, then they can act accord­ing­ly in an informed way based on what we have been doing in sci­ence know­ing what works for pain, what works for sleep and that they could try some dif­fer­ent strate­gies. Because if you talk to pain patients or insom­nia patients, they feel like they are stuck in a vicious cir­cle. So they don’t know how to get out so in ther­a­py main­ly what we do is just to pull them out a lit­tle bit and see what they are fac­ing and what are their options for them in terms of treat­ment and then gen­tly lead them to a way that will help them to main­tain their sleep.

And usu­al­ly the strate­gies that we sug­gest to them are very counter intu­itive – let’s say you want to have bet­ter sleep actu­al­ly the best way is to not lie in bed for so long try­ing to get to sleep. When you’re dying to get some sleep per­haps the best way to reg­u­late your sleep, so that your sleep could be con­sol­i­dat­ed, you will be crav­ing sleep at the right time so that you can con­trol the tim­ing of sleep and you don’t have to wait for hours in bed, toss­ing and turn­ing and yet sleep doesn’t come.

Evans: So how dif­fi­cult is it to per­suade some­one with chron­ic pain to change the way they think about their sleep. Nicole Tang again.

Tang: It is incred­i­bly dif­fi­cult to get peo­ple to do some­thing that they think is not going to help with sleep. That is why in treat­ment I usu­al­ly start with a ses­sion of sleep edu­ca­tion. So it’s not just about sleep hygiene – giv­ing them the tips, what to do to get a good night’s sleep – it’s actu­al­ly to help them under­stand how sleep works. Peo­ple think that the longer they sleep the bet­ter they will feel the next day and in fact it’s not nec­es­sar­i­ly the case. There is the con­cept that when we get suf­fi­cient sleep for the first few hours of your sleep cycle, it is suf­fi­cient to get you going for the next day.

Sleep in a way is like an appetite it’s like eat­ing choco­late, so if you eat too much choco­late there will be a point when you think that I don ‘t need that much choco­late and it will be nicer if I eat less choco­late. So sleep is just the same. So we will have to get peo­ple to under­stand that sleep doesn’t work in such a way that the more you get it the bet­ter you feel and to under­stand that if you try too hard to go to sleep, sleep won’t come. It’s just like a but­ter­fly – if you try to grab it, it will just fly away.

So we help them to do some­thing new, to try some­thing dif­fer­ent. So apart from chang­ing the way they think about sleep, we also help them reg­u­late their sleep sched­ule. So let’s say that the main prob­lem is that they spend too much time in bed, we will help them to set up a new sched­ule of sleep, so that they will post­pone their sleep time and then get up at the same time so that they will save up some of their sleep pres­sure, if I may say, for the next day. So that the next day by the time when they are about to get to bed they will feel sleepy enough and they will just plunge into sleep faster than they would if they go to bed early.

So we help them to use a new sleep sched­ule, use a new strat­e­gy to deal with mid­night awak­en­ing because a lot of time when you wake up in the mid­dle of the night because of the pain it could be very frus­trat­ing. So we have to help them to focus and think­ing of a bet­ter way of react­ing to these kind of pain relat­ed arousal. First of all by not being too frus­trat­ed by the fact that you wake up because actu­al­ly if you look at nor­mal people’s sleep, even the best sleep­er on earth, they will have a num­ber of awak­en­ings dur­ing the mid­dle of the night. But why don’t they com­plain about wak­ing up in the mid­dle of the night – is it because a lot of the time they don’t remem­ber they have been wok­en up for no par­tic­u­lar rea­son? Because also they can fall back to sleep rel­a­tive­ly quick­ly, so those awak­en­ings will not be reg­is­tered in the memory.

So we’re using tricks like that to help them to per­haps go back to sleep quick­er, be more accept­ing of them awak­en­ing – know­ing that per­haps it could be a good thing for them, because if you wake up that could give you a chance to adjust your body posi­tion so that you can feel more com­fort­able in bed. So by con­sid­er­ing all sorts of dif­fer­ent issues sur­round­ing the arousal with the new under­stand­ing: why peo­ple wake up; what are the con­se­quences of wak­ing up in the mid­dle of the night? what are the con­se­quences if I react bad­ly or frus­trat­ing­ly to the awak­en­ing? what will I do next know­ing all these consequences?

So we help them to per­haps think of a strat­e­gy to get out of the bed­room so they don’t wor­ry in bed and think, ‘what should I do now that I can’t sleep?’ Go to anoth­er room, do some­thing bor­ing – know­ing for sure that the bor­ing task will help them to fall back to sleep. So that they feel much more in con­trol of what they do with the insom­nia and usu­al­ly with­in two weeks using this sched­ule and some new method of help­ing with their sleep, the sleep will turn out to be quite beau­ti­ful and a lot of peo­ple that I’ve treat­ed have shown sig­nif­i­cant improve­ment to the point that they sleep almost like nor­mal sleepers.

Evans: Dr Nic­hole Tang of the Insti­tute of Psy­chi­a­try. And I would just like to draw your atten­tion to the British Pain Society’s new Spe­cial Inter­est Group for Pri­ma­ry and Com­mu­ni­ty Care. It’s inau­gur­al meet­ing is hap­pen­ing at BMA House in Lon­don on Sat­ur­day the 9th of April 2011 and it will be cheered by Dr Mark Porter M.B. and Chair of the British Pain Soci­ety, Pro­fes­sor Richard Lang­ford. And you can get all the details from the British Pain Soci­ety web­site and Air­ing Pain is plan­ning to fea­ture it in a future edition.

As promised, we will end this ses­sion with Edith Mowatt’s expe­ri­ence with liv­ing and cop­ing with nerve root pain. But don’t for­get that you can still down­load all the past edi­tions of Air­ing Pain from our web­site at painconcern.org.uk. And if you want to put a ques­tion to our pan­el of experts or just make a com­ment about our pro­gramme then please do so via our blog, mes­sage board, email, face­book, twit­ter. Here’s Edith Mowatt:

Mowatt: Ini­tial­ly, it kind of colours your whole life, but you begin to learn to con­trol it and not let it con­trol you. I found that high pow­er drugs like mor­phine, all they did was addle my brain and seemed to make the pain more acute – they seemed to sharp­en it, if that makes any sense. But once you get onto a regime of painkillers that suit you, you begin to be able to con­trol the rest of your life and con­trol the pain with – how would I put it? Not med­i­ta­tion, but you learn to be in a qui­et place away from the pain; you learn to put the pain some­where else. I use a tech­nique of visu­al­i­sa­tion, in that, I can, even as I speak to you now, that if the pain is real­ly bad, I could take myself on a jour­ney and put the pain some­where else away from me.

Go to some­body else who is in pain and can help you and teach you the visu­al­i­sa­tion tech­niques, as I say – the way to be just in a qui­et place and put the pain some­where else, so as you can get on with your life. I admit that there are still days when the pain con­trols me and you real­ly won’t want to be around when that’s hap­pen­ing. But the bad days are real­ly vile and the good days are many more than they used to be – many more than they used to be. But you have to be pos­i­tive; if you’re neg­a­tive all the time the pain will seem worse, much, much worse! You have to be pos­i­tive and you have to focus on what you can do and what it’s allow­ing you to do and go that step fur­ther every day. Just take it that step fur­ther. You can do it!


Con­trib­u­tors:

  • Edith Mowatt, Nerve Root Pain
  • Dr Steve Gilbert, Queen Mar­garet Hos­pi­tal, Fife
  • Pro­fes­sor Can­dy McCabe, Com­plex Region­al Pain Syn­drome, Phan­tom Limbs and Mir­ror Therapy
  • Pro­fes­sor Mark Bla­grove, Sleep and Pain
  • Dr Nicole Tang, CBT and Sleep.

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