Beth: Welcome to another episode of Fresh Focus. I’m Beth your host today. I’m a Registered Dietitian Nutritionist here at the Marion VA. The month of September has been declared Pain Awareness Month. I actually read that it was established as pain awareness month in 2001 so 20 years now. Pain Awareness Month is noted to be a time when various organizations work to raise public awareness of issues in the area of pain and pain management…so we thought it was a perfect time to start discussions on the pain and nutrition connection. Healthy food choices can improve your overall health, help achieve a healthy weight, give you more energy and help reduce pain. Food is information to your body and certain foods can increase inflammation and worsen chronic pain and We as dietitians want to be able to assist and also want to make sure for those of you out there listening have information to aid in pain management. That is why I’m sitting here today with Judy Bishop. Thank you so much for being on today. I really appreciate it. Tell our listeners a little about yourself and your position and how long you have been at the VA.

Judith: well Thank you very much for having me. I have worked as an RN for 36 years. I received my BSN from SIU-Edwardsville. 24 years at SIH and 12 years here at the VA. My positions at the VA predominantly were in the Pain Clinic and currently in Out Patient Orthopedic Clinic.

Beth: Right awesome, I have heard you talk about the pain clinic we have what we all the pain boot camp, tell our listeners What all that entails?
Judith: The Pain Workshop (also known as the Pain Workshop) is an Interdisciplinary Team that teaches Veterans what pain is and how they can manage it and live a fulfilled life with joy & satisfaction despite pain. This goal (to teach what pain is and how to manage it) seems a simple concept. For patients with pain, it is not simple, it is complicated. Pain affects the mind, mental outlook, interpersonal relationships, work responsibilities, physical abilities, our finances, and everything. In the Workshop, we start off recognizing that Pain is Real, it is not made up. With a diagnosis or without a diagnosis, Pain is real. The Pain Workshop is held every month on the 3rd and 4th Thursday from 8:00 a.m. to 12:00 noon. It is currently done using VVC format. Our goal is to return to offering it again Face to Face as soon as we can. We have a strong interdisciplinary team, most of the team has been a part of the Pain Workshop since it’s inception since 2013. We have a pharmacist, Physical Therapy, Social Work Addiction Specialist, Nutrition/dietitian, OIF/OEF Case Manager, Voc Rehab Specialist, Pain Social Worker, Whole Health Manager, and Pain RN. Each Team member educates patients on pain management techniques from their specialty area. The Pain Workshop is unique as it brings all these Specialist and their knowledge to the Veteran in a formal setting that allows them to learn and ask questions about Pain, a chronic health condition. If Veterans express a desire to learn more about information presented during the Workshop, we assist them, we alert their PCP for necessary consults (Physical Therapy, Behavior Medicine, Chiropractic, Acupuncture). We also provide the Veterans with written list of Marion VA resources available to them with contact names & numbers (Move Program, Whole Health, Tai Chi, Mindfulness, Nutrition).
Beth: I love that I love the whole team approach. What are some differences between Successful Pain Management and Poor Pain Management?

Judith: Successful Pain Management begins with a relationship between the Provider and the Patient that is based on respect, trust, listening, and compromise. Successful Pain Management involves setting identified goals & a treatment plan that is agreed upon by patient and Provider. Characteristics of Successful Pain Management include patients that take pain medications responsibly, expect and achieve some reduction in pain (not complete pain relief), improved independence & function, improved physical endurance & activity tolerance, improved self-esteem & social interaction, improved self-management of their pain (able to cope better on bad days), and over all have a higher Self-rating of their health with decreased use of health care resources.
Characteristics of Poor Pain Management include patients that continue to report high levels of pain, who rely only on medications for relief of pain, who overall self-rate a poor health status, has a higher use of healthcare resources (more phone calls to the doctor and more visits with MD), decreased socialization with family and friends, higher levels of emotional distress, and not all patients, but some have a higher use of alcohol, tobacco use, diet/weight concerns.

Beth: I’ve heard you mention the concept of Pain Gate Theory before do you want to talk a little more about that.

Judith: Physical Pain is transmitted to the brain by stimulated nerves. When this happens the Pain Gate is open. Pain is experienced. The Pain Gate can be closed by non-pain input. Input from physical influences (activity, heat, stretching), cognitive
thoughts (distraction, positive thinking, capturing and changing negative thoughts),
and emotions (reduce stress, optimism, mindfulness) can stimulate nerves that
close the Pain Gate. The concept is: Pain (acute or chronic) is multifaceted and
can be modified/managed by using multifaceted approaches employing physical,
cognitive, and emotional health interventions. For our pain patients, understanding
this is empowering and necessary to manage pain successfully. This is what we try
to teach. Each presenter incorporates the Pain Gate Theory in their talk.
Example not using Pain Gate:
Veteran: “My back hurt when I went to bed and hurts when I got up. I can’t do anything. I am cancelling my plans, I am going back to bed. This is a horrible day”
Veteran using elements of The Pain Gate Theory: “My back hurts and I haven’t even gotten out of bed. I am going to try some stretches(employing physical modalities). I had plans to go out for lunch, I don’t want to miss this (optimism). I have had bad days like this before, I was able to get through it (positive thinking). If I don’t feel better after stretching, I will see if my friend will pick up lunch to go and come over (does not isolate).

Beth: I love those examples. So what is the different approaches to managing Acute and Chronic Pain?

Judith: Acute Pain is a pain that has lasted 3-6 months. It is managed under the Bio-
Medical Model. The Medical Model approach consists of treating patients with medical interventions such as medications, medical procedures, surgery, specialists. Acute Pain is usually a result of an injury or strain, usually quick/easy to diagnose & treat. The nervous system turns on an alarm to alert our body of injury/pain. Once the injury heals, the nervous system goes back to normal and the fire alarm goes off.
Chronic pain is a pain that lasts 6 months or longer. It is best managed under the Bio- Psycho-Social Model. The Bio-Psycho-Social Model emphasizes patient involvement managing their Chronic pain/illness, effectively uses Self-Management goal setting, action planning, problem solving, and FOLLOW UP. Chronic Pain persists beyond the normal healing time of an acute injury, is often resistant to medical treatments, and the nervous system stays in a persistent state of activity. The fire alarm doesn’t turn off. This over-reactive nervous system leads to vicious pain cycle leading to anxiety, poor sleep, fatigue, & depression. In the Pain Workshop we teach Veterans how to break this vicious pain cycle.
Every patient starts out being managed under the Medical Model and hopefully a
treatment resolves their pain. But when a diagnosis or successful treatment isn’t found
(pain continues). If patients don’t get relief, they may change doctors out of frustration and repeat the same treatment over, hoping it will work this time. The treatment approaches eventually changes to the Bio-Psycho-Social Model.
When this happens, it is not always explained to the patient. Patients may hear “there is nothing I can do to help you”. In the Pain Workshop we discuss these different approaches. We ask the patients: Where do you see yourself? Medical Model or Bio-Psycho-Social- Model?

Beth: so in the pain boot camp I know you guys set SMART Goal how can you help a veteran set a SMART goal do you want to give an example?

Judith: Here is a common SMART goal many patients identify to work on: Improve my physical condition through physical exercise.
In this scenario, we ask the patient what are the benefits of improving their physical
condition? We want to know why they want to do this? Patient response: I would
like to walk to the mailbox and get my mail, I miss this, it gets me outside, I feel independent.
Once we identify the benefits, we find out what their physical activity is now? This
allows setting Specific, Measurable, Action oriented, Realistic goal that
is Trackable. This is an actual true veteran. The Veteran states after walking 2 minutes he needs to sit down. He estimates it would take him 4 minutes to walk to his mailbox and back to the house. He agrees to this goal: I will walk in my house at least three times a day for 2 minutes. At two weeks, I will increase my walking to 3 minutes in the house 3X/day. At four weeks, I will increase my walking to 4 minutes in the house 3X/day. At six weeks, I will walk to my mailbox and place a lawn chair
halfway to the Mailbox to rest if I need to.

Beth: I love that we use SMART goals a lot in talking to our veterans to be specific like you said measurable action oriented realistic trackable and time based and Such great information for all our veterans and listeners. Thank you so much for being on here with me today! Please reach out to your primary care provider for information in your area for pain management resources. Remember to contact your local VA Dietitian for tips on planning your very own anti inflammatory plate to help reduce inflammation. Thank you to everyone listening and stay tuned for more episodes in this nutrition and pain series! Please be sure to subscribe to this podcast rate the series and leave a review.