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This packet is designed for individuals who have participated or are currently participating in the active trainings provided by the Pain Management Team. These activities are comprehensively included for the Foundations of Pain Management Trainings and do require formal guidance prior to participation. Included are supplementary information not currently found in the primary WORKBOOK. Pain Management Clinic Contact Information: Vacaville: 707.624.3328, kp.org/Vacaville/painmanagement Vallejo: 707.651.4490, kp.org/Vallejo/painmanagement *Please bring this packet with you to all Foundations Trainings.

Foundations of Pain Management Supplemental Workbook

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Online General Persistent Pain Resources

Video and Literature Resources

Video Clips Website: www.youtube.com Title: * Why Things Hurt by Lorimer Moseley (14 min)

▪ https://www.youtube.com/watch?v=gwd-wLdIHjs * Tame the Beast by Lorimer Moseley (5 min) ▪ https://www.tamethebeast.org/#home

* Understanding Pain in Less Than 5 Minutes by Brainman (5 min) ▪ https://www.youtube.com/watch?v=5KrUL8tOaQs

* Neuroplasticity by Sentis (2 min)

• https://www.youtube.com/watch?v=ELpfYCZa87g * An introduction to mindfulness by Mindfulnet (3 min)

* Mindfulness and Chronic Pain by Jon Kabat-Zinn (4 min) * Explaining chronic pain: The role that stress plays and the creation of learned nerve pathways by Howard Schubiner, MD (9 min)

* The Role of Pain in the Brain, The MindBody Syndrome (9 min) Purpose: To help you gain greater knowledge of chronic pain

Book Recommendations Title: * Full Catastrophe Living by Jon Kabat-Zinn and Thich Nhat Hanh * The Brain’s Way of Healing by Norman Doidge

* The Brain That Changes Itself by Norman Doidge * Chronic Pain: Your Key to Recovery by Georgie Oldfield

* The MindBody Prescription by John Sarno * The Pain Survival Guide by Dennis Turk PhD and Fritz Winter PhD * Reality Slap by Russ Harris * The Mindfulness Solution to Pain by Jackie Gardner-Nix and Jon Kabat-Zinn * Why Do I Hurt by Adriaan Louw * Explain Pain Handbook by David Butler and Lorimer Moseley * Why We Sleep by Matthew Walker, PhD * Say Goodnight to Insomnia by Gregg Jacobs, PhD Purpose: To learn more about how to decrease physical & emotional reactivity. To help you gain greater knowledge and application of Thought Management and Mindfulness.

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Guided Imagery Podcast • Kp.org/listen

• Pain, Stress, Anxiety & many more Step 1: Go to: kp.org/listen or kpdoc.org/podcasts Step 2: (On left menu) Click on: Podcasts Step 3: (Locate Health Conditions) Click on:

▪ Pain, Stress, Sleep, Anxiety, or Fibromyalgia. * Please choose one main podcast to use for at least a month. * Please use headphones * Please listen 1-2 x a day

CALM and My Strength Applications • As a Kaiser Permanente member, you can sign up for free using the following link: ▪ https://healthy.kaiserpermanente.org/northern-california/health-wellness/mental-

health/tools-resources/digital?kp_shortcut_referrer=kp.org/selfcareapps

YouTube Mindfulness Practice • Kabat-Zinn body scan and sitting meditation:

▪ https://www.youtube.com/watch?v=15q-N-_kkrU (30 min) ▪ https://www.youtube.com/watch?v=524RMtfHKz8&t=919s (20 min)

UCSD Guided Practice Mindfulness • https://health.ucsd.edu/specialties/mindfulness/programs/mbsr/pages/audio.aspx

Wellness Phone Coach • Manage Stress, Eat Healthier foods, Achieve Healthier Weight, Smoking Cessation

• Call 1- 866-251- 4514

Clinical Health Educators: Health Education Department (Vacaville 707-624-2225)

• Brandi Bell, CHE: 707-624-2618

• Chetendeep Lal, CHE: 707-624-2234 ▪ Manage: life care planning, cholesterol, Diabetes/meter teach, pre-diabetes,

hypertension, healthy eating, stress management, weight management, physical activity (currently no referral necessary/ in person visit)

• Please utilize the Health Education Department for additional classes: ▪ Sleep, Anxiety, Stress Management, and many more

Learn more at: kp.org/Vacaville/painmanagement

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Below is a comprehensive list and the corresponding links to the referenced resources in the presentations and/or on the slides: Class 1

1. Slide 8

• Sentis Neuroplasticity video (2 minutes)

▪ https://www.youtube.com/watch?v=ELpfYCZa87g

• Tame the Beast (5 minutes)

▪ https://www.youtube.com/watch?v=ikUzvSph7Z4

2. Slide 24

• Stress Management: Breathing Exercises for Relaxation

▪ https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.stress-

management-breathing-exercises-for-relaxation.uz2255?kpSearch=deep%20breathing

Class 3 1. Slides 16-17

• How to Form Healthy Habits – BJ Fogg, PhD

▪ Search “Tiny Habits” on YouTube : Forget Big Change, Start with a Tiny Habit

1. https://www.youtube.com/watch?v=AdKUJxjn-R8

▪ Visit kp.org/watch > Videos > How to Form Healthy Habits 1. https://healthy.kaiserpermanente.org/health/care/consumer/ancillary/!ut/p/a1/hY9Bj4IwEIV_iweOZkbZIHIDk

12xrmI0gr2YLlZtLIV0J0b-

vYgxntR3m8z38uUBhwy4EWd1EKRKI_Tt5t72e7KcR1EvxPnX0Mf4dzQexTOGTSCFCfCDLv9aeHMkqgIHHcxLQ9K

QlWYnrbQOAs-priRkyuxLWzwFbzukdpClSRIEM1wmPou8waeKuGuEyZXWwtYfFUYUDf-

vSG7b94WaVbwdjm68aIf_JB5i7LMVWw-

Zi9h_AC8SIlSFX7v6PJVp97QIO50rXTXaJA!!/dl5/d5/L2dBISEvZ0FBIS9nQSEh/

2. Slide 23

• Sleep Better Resources

▪ Go online to kpdoc.org/wellnesscoaching

1. https://mydoctor.kaiserpermanente.org/ncal/promotions/#/wellnesscoaching

2. Topics include: Insomnia, Nutrition, Exercise, Stress Reduction, Smoking Cessation

▪ kpdoc.org/sleep

1. https://mydoctor.kaiserpermanente.org/ncal/staying-

healthy/#/conditionlist/diseasesconditions_174130.xml

▪ kpdoc.org/healthfulsleep (podcast)

1. https://healthy.kaiserpermanente.org/health-

wellness/podcasts?kp_shortcut_referrer=kp.org/listen

▪ kp.org/dream

1. https://healthy.kaiserpermanente.org/health-wellness/healthy-lifestyle-

programs?kp_shortcut_referrer=kp.org/dream

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Class 5 1. Slide 23-24

• Meditation audio and transcripts

▪ kp.org/selfcaretools

1. https://healthy.kaiserpermanente.org/health-wellness/mental-health/tools-

resources?kp_shortcut_referrer=kp.org/selfcaretools

▪ kp.org/self-compassion

1. https://healthy.kaiserpermanente.org/health-wellness/mental-health/tools-resources/self-

compassion?kp_shortcut_referrer=kp.org/self-compassion

▪ Meditation for Pain Relief (guided imagery)

1. https://healthy.kaiserpermanente.org/northern-california/health-

wellness/podcasts/conditions-diseases/pain-management

▪ Other options:

1. Kp.org/listen: (same as Kp.org/podcasts)

a. https://healthy.kaiserpermanente.org/health-

wellness/podcasts?kp_shortcut_referrer=kp.org/listen

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Persistent Pain Active Practice Resources Below are the supplemental active based practices not referenced in any detail in the primary workbook but vital to your learning experience.

Noticing Worksheet

Safe Factor/Activity Threatening Factors/Activity

Begin to identify and track movements, activity and other factors, such as stressors, that impact/affect your pain or symptoms. It is very important that you are able to develop strategies around these factors as they are being retaught to your brain and body. With the ability to navigate what your brain is registering as a threat/danger you can more efficiently retrain your brain. Also, it is very important that you and your brain are able to emphasize the safe factors as to overtake the dangers/threats and more appropriately reinstate function/activity and make progress on your journey.

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Pacing at Home

• Plan to set aside time to explore your pacing techniques.

• Choose things that are more “threatening” and alternate them with things that are “safe”.

• Notice what thoughts arise as you plan. What are you telling yourself?

• Next, go ahead and DO the activities as planned. How did it work out? How do your pains feel?

Activity Time Safe or Threatening

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Relaxation & Mindfulness Strategies

4-7-8 Breathing

• Practice and your brain will create a superhighway inducting you into a relaxed state of letting go, peace. ▪ Step 1: Notice your breathing (any aspect of your breathing is ok). ▪ Step 2: Breathe in for the count of 4, hold for 7, and breathe out for the count of 8. ▪ Step 3: Each time your mind wanders off bring it back to your breathing.

• Purpose: To quiet your mind down, which reduces the pain and emotional signals, and thereby giving you greater control.

▪ Tip: Place your hand on your abdomen and feel it move in and out as you breathe. Gradually slow

your breathing down—exhale a little more with each breath.

Hand Technique

Prior to beginning: • Ask yourself: What is my tension/pain level right now?

Active Practice:

• As you breathe in…raise your thumb…gently hold…as you slowly breathe out say: I am releasing all unnecessary tension in my body down to zero now—thank you

• Next…as you breathe in…raise your index finger…gently hold…then say, again, as you slowly breathe

out… I am releasing all unnecessary tension in my body down to zero now—thank you.

• Continue through until your pinky finger.

• When done, ask yourself, again: What is my tension/pain level right now?

▪ Tip 1: If your tension/pain level has gone down –even one number down—great job! If no change, no worries. Just repeat one more time.

▪ Tip 2: If you use this skill every day 2-3 x a day for the next 2 weeks, you will receive more stress reduction and more pain relief.

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Mindfulness of the Breath – 3 Minute Breathing Meditation

As we all know from personal experience, our mind has a tendency to wander. This takes a toll on our mind in the form of increased suffering and unhappiness (Killingsworth & Gilbert, 2010). It’s therefore very important to find an anchor, something to center us in the moment in order to come fully into the here-and-now. Our breath serves as a perfect instrument to accomplish this goal. Our breath is always with us, operating automatically. For 24 hours a day, for every day of our lives, our breath is there like a trusted companion. Wherever we are, and whomever we are with, we can always turn to the breath as a means of grounding ourselves in the present moment. Because of this, our breath will be the focus of our first mindfulness meditation.

Instructions: Begin by finding a comfortable, peaceful place to sit. Set aside around ten minutes to start with,

though you can extend this as you wish in the days to come. Sit down in a manner that’s comfortable, either in a chair or on the ground. Keep your back straight, allowing your shoulders to relax. Close your eyes, or choose a spot on the floor in front of you to focus your gaze.

• Begin by taking three easy and gentle breaths in through your nose, followed by slow and steady exhales.

With each breath, feel yourself slowing down and becoming more immersed in the moment.

• If you notice your mind wandering or your thoughts drifting, simply notice this and return your attention and awareness to your breath. You may notice your mind wandering at many points during this meditation; it’s simply what our mind does. Merely observe this tendency, and without judgment, return your awareness to your breathing.

• Bring full attention now to your breathing. As you inhale and exhale, observe where in your body you notice your breath the most. Perhaps it’s in your chest, as you feel it rise and fall with each breath. Others notice their breath most strongly in their nostrils, as the air passes coolly on the way in, and slightly warmer on the way out. Still others notice the breath most clearly in their stomach and abdomen, as it rises and falls with each passing breath. Wherever it is, take a moment to simply notice where the breath is most clearly felt in your body.

• Notice how it feels to fully focus on your inhale. As you inhale, notice any particular feelings of tension or strain, and notice the sensation of your lungs and abdomen filling up as you inhale.

• Now gently shift your awareness to focus more on your exhale. With each exhale, notice what it’s like to feel your breath passing out through your nostrils. And observe, without judgment, anything that you feel in your body.

• For the next few minutes, continue to breathe gently and evenly. Feel the breath as it comes in through your nose, followed by a steady exhale.

• Notice what’s happening in your mind. If you notice your mind wandering or your thoughts drifting, don’t judge yourself or react self-critically. Simply notice this, and gently redirect your attention and awareness back to your breathing.

• After ten minutes, gently open your eyes and bring your awareness back to your surroundings. Allow yourself to bask in the comfort and tranquility of the present moment.

For beginners in mindfulness, this exercise can either be eye-opening or frustrating. You may have noticed your mind becoming flooded with thoughts or judgments, and that’s okay. It’s our mind’s natural tendency to drift and seek out stimulation, and maintaining focused awareness on the breath may feel unnatural initially. But through practice and patience, it becomes easier over time. With practice, you’ll even grow to find immense comfort and safety in your breath, which you can turn to whenever you want.

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Mindfulness of the Senses

• Begin by finding a comfortable, peaceful place to sit. Set aside around 10 minutes to start with when beginning this practice, though you can of course extend this time further in the days to come. Keeping you back straight, allow your shoulders to relax. Close your eyes if you’re comfortable doing so; otherwise, choose a spot on the floor in front of you to softly focus your gaze.

• Begin by taking three gentle and easy breaths, in and out of your nose, followed by slow and steady exhales. With each passing breath, feel yourself slowing down ever so slightly, and become more immersed in the moment.

• If you notice your mind wandering or your thoughts drifting, simply notice this and return your awareness and attention to your breath. This may occur at many points throughout this meditation; it’s simply what our mind does. Merely observe the tendency of your mind to wander, and without judgment, return your awareness to your breath.

• Bring full attention now to your breathing. Notice the sensation of your breath as it enters and leaves your body. With each passing breath, observe yourself becoming more present in this moment.

• When you’re ready, bring your attention now to the sounds around you. Notice the sound of your breath, slowly in and slowly out. Notice even the faintest of sounds that you can detect around you. And notice the silence as well. Imagine your ears as satellites, able to pick up on any and all sounds that surround you in this moment. Simply notice these sounds, without judgment, and without any desire for things to be different than they are.

• Bring awareness now to any smells that you can detect. As you inhale, observe any scents, whether they are strong or faint, that you nose picks up on. Observe any judgments that arise, and simply notice those as well. Take a few moments to fully observe any scents and smells that you can detect.

• Shift your focus now to feeling your body, sitting in your chair or on the floor. Notice the weight of your body being supported beneath you. Become aware of the texture of the fabric of your clothing against your skin, the temperature of the air against your skin. Notice your hands and feel them resting wherever they are placed. Take a few moments to fully notice all of this.

• Now bring your awareness to any tastes that you can detect in your mouth. Whether faint or strong, simply observe any and all tastes that you’re able to detect. If you’re unable to, simply notice that as well.

• With your eyes closed, imagine what the room likes like around you. Paint a picture in your mind’s eye of what surrounds you right here in this moment. Try picturing the walls, the floor beneath you, the colors of the room. Take a few moments to visualize your surroundings.

• Now notice what’s happening in your mind. Are your thoughts looking up ahead towards the future, backwards to the past, or are they here and now in the present moment? Without judgment, simply notice where your mind is taking you. If you catch your mind wandering or your thoughts drifting, don’t judge yourself or react self-critically to this. Simply observe this, and gently redirect your attention and awareness back to your various senses.

• After around ten minutes has gone by, gently open your eyes, and bring your awareness back to your surroundings. Allow yourself to bask in the comfort and tranquility of the present moment for a few more moments.

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Leaves on a Stream

1. Sit in a comfortable position and either close your eyes or rest them gently on a fixed spot in the room.

2. Visualize yourself sitting beside a gently flowing stream with leaves floating along the surface of the water. Pause 10 seconds.

3. For the next few minutes, take each thought that enters your mind and place it on a leaf… let it float by. Do this with each thought – pleasurable, painful, or neutral. Even if you have joyous or enthusiastic thoughts, place them on a leaf and let them float by.

4. If your thoughts momentarily stop, continue to watch the stream. Sooner or later, your thoughts will start up again. Pause 20 seconds.

5. Allow the stream to flow at its own pace. Don’t try to speed it up and rush your thoughts along. You’re not trying to rush the leaves along or “get rid” of your thoughts. You are allowing them to come and go at their own pace.

6. If your mind says “This is dumb,” “I’m bored,” or “I’m not doing this right” place those thoughts on leaves, too, and let them pass. Pause 20 seconds.

7. If a leaf gets stuck, allow it to hang around until it’s ready to float by. If the thought comes up again, watch it float by another time. Pause 20 seconds.

8. If a difficult or painful feeling arises, simply acknowledge it. Say to yourself, “I notice myself having a feeling of boredom/impatience/frustration.” Place those thoughts on leaves and allow them float along.

9. From time to time, your thoughts may hook you and distract you from being fully present in this exercise. This is normal. As soon as you realize that you have become sidetracked, gently bring your attention back to the visualization exercise.

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Movement Practice Strategies

Diaphragmatic Breathing

Breathing is a natural and automatic act that has direct affect on your pain and stress/sympathetic nervous system state as well as your general wellbeing and health. It is often employed during relaxation and mindfulness strategies, but understanding the basic mechanisms of the movement is important to efficient use of these strategies. This is a practice that will often take time to re-establish and to become comfortable.

• Place one hand on your chest and one on your belly/abdomen in a neutral postural position. ▪ By gently placing your hands on your chest and belly/abdomen, you are providing feedback to

your brain and improving your ability to engage your diaphragm.

• Emphasize the “belly” hand during inhalation. ▪ Your abdomen should expand without your chest rising. ▪ This may feel very difficult as you begin your practice.

• You may also improve this ability by varying your position. ▪ Lying on your back or in a reclined position is often a great place to begin the re-learning

process of diaphragmatic utilization.

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Pelvic and Scapular Clocks

The pelvis and the scapula are often amongst areas that are highly emphasized in the rehabilitative process. These sites are very important to the reconnection of your trunk to your extremities and vital to the overall function of your body and postural development. Pelvic Clocks

• Begin in a neutral postural position.

• Imagine that you are sitting on a clock & that 12 o’clock is oriented towards your front and six toward your back. ▪ The orientation will change if lying on your back or in a reclined position: 12 is towards your head, 6 is

towards your feet

• Gently and intentionally rock your pelvis in a 12-6 pattern. ▪ This should be done independently from your full spine and chest (you should not involve your whole back by

arching or fully rounding).

• Consider partial range and slow pace for noticing development and tolerance.

Scapular Clocks

• Begin in a neutral postural position.

• Imagine that you have a clock face on the center of your shoulder and that 12 o’clock is oriented upwards/towards your head and six downwards/towards your feet.

• Gently and intentionally move your shoulder blade in diagonal or circular patterns around an imaginary clock. ▪ This should be done independently from your full spine, chest and head (you should not involve your whole

back by arching or fully rounding and your head should remain neutral without jutting forward). ▪ Consider clockwise and counterclockwise directions to explore.

• Consider partial range and slow pace for noticing development and tolerance.

12

6

12:30 5:30 11:30 6:30

12 12 12

6 6 6

6 12 6 12

12 6

12 6

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Spinal Mobility

Spinal movement and the ability to utilize said movement is key for overall mechanical function, other joint function and postural maintenance/development. Noted here are some variations of spinal decompression strategies/positions for offloading the system and potentially symptom management and mobility options for decreasing stiffness and regaining movement where necessary. Spinal Decompression Spinal Rotation

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Posture

The positions your body repetitively resides in will ultimately influence your function and often your symptoms. It is very important that your postural awareness is a formal part of your noticing practice as it will contribute to your systemic wellbeing. Efficient posture is the foundation to all human performance and systemic function including, but not limited to muscle, joint, fascia, nerves, organs. The primary characteristics of non-dynamic posture (i.e. sitting and standing) are the following:

• Stacked and/or Balanced – work with gravity not against. ▪ Head and Neck → Shoulders → Trunk → Pelvis on Pelvic Floor → Lower Extremities and Feet

• Relaxed – your muscles should be relatively “quiet” here. Unsupported Seated Posture General Standing Posture

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Flare Management Strategies

Flare Plan

A flare-up refers to a period of more intense pain or symptoms that is felt more severely during day-to-day persistent pain. A pain flare is by definition not a new pain/symptom, it is part of a chronic condition. During a pain flare you should try to modify your activity, behaviors & thoughts to help yourself work with the flare. All of the skills addressed in the Foundations of Pain Management Classes are options for utilization during flares. Make a plan, work with it and be consistent. Below you will find a workable construct/template to start your Flare Plan. Feel free to deviate from the Department’s provided selections if you have other valid and relevant options but stick to the plan. *Attempt to consistently use active therapy options as they are most effective for long term benefit.

1. I will remember to breathe and use relaxation or meditation strategies:

2. I will use these strategies to manage unhelpful thoughts:

3. I will continue these gentle exercises/stretches:

4. I will use strategies that will help me to continue and/or resume activities (example- pacing):

5. I will remember to utilize my support system:

6. I will use tools/devices as recommended by my clinician (example- ice, heating pad, massage tool):

A secondary way to look at the Flare Plan construct is as follows:

Things you do every day to prevent your flares:

1.

2.

3.

4. * It is important to understand that there are many things you can do in your daily lifestyle that can lessen the intensity/frequency/duration when flare occur or even prevent flares from occurring at all.

Things you do for days when you have a pain flare:

1.

2.

3.

4.