Introduction Challenging, persistent pain needs the skills of more than a single professional. This is why, at Dunedin Hospital, we use a team approach. Why use a team approach Because persistent pain is a complex problem, you can meet a team of professionals with different backgrounds at your first Pain Clinic appointment. They are used to helping people deal with persistent pain. In Dunedin, the assessment team can include an anaesthetist, clinical psychologist, psychiatrist, nurse, occupational therapist and physiotherapist. Sometimes there are dental staff and trainees/students present. At times, a single team member will make an initial assessment and give preliminary advice. Arrangements for others in the team to assess you can follow. A typical assessment Team members usually meet you as a group to avoid duplication of questions, but sometimes it can only be done individually. We will get a detailed history of your pain problem. This involves many questions so we can try to fully understand what is happening for you, including the impact on your life, work, and family and recreational activities. You will then be examined by some of the team members. Because pain can radiate/refer to other areas of your body, or be part of a widespread process, the examination usually includes other areas as well as where you hurt. Wearing suitable clothing can help or you may be asked to put on a patient gown. We may ask you to fill out questionnaires at different stages following initial consultation or other interventions with the service. This helps us to see if we are meeting your needs. Team members will discuss and assess the information they gather to be able to advise you on the best advice to offer. You will be asked to sit in the waiting room while this is being done. It helps to bring something to do, e.g. something to read. After the team discussion, there will be a discussion with you of their assessment of the problem and options to help you manage your pain. Your input is an important part of that discussion - after all, it is your problem and the more you understand it, the better equipped you will be to carry out suggestions and move forward. How long will it take? A full assessment and explanation usually takes up to two hours - so allow enough time so that this can be done fully. Follow-up visits It is common to see you again, unless it is agreed between you and the team at the initial assessment that it is not necessary, or you do not wish to. A shorter time is usually scheduled for follow-up visits; usually 15 - 30 minutes. Treatment Any proposed treatment will be discussed with you. Help may come from a range of measures, rather than a single treatment. You do not have to undergo any treatment if you don’t want to. Any other considerations? You may have particular needs that we may not be aware of, e.g. religious, gender, cultural concerns, or other factors such as sensory impairment (e.g. hearing, vision). Please contact us if there is anything we need to know. What can you do to help? · Please confirm your appointment or let us know if you cannot attend. This helps us to use the clinics more efficiently to keep waiting times as short as possible. · Please bring a list of current medications · Please bring your reading glasses if you use them. · Should I write everything beforehand? No. It is better to have a two-way discussion with you to get useful details about your problem. But, if you have questions you hope to have answered at the assessment, it can help to write them down! · Can I bring someone with me? Attending with someone else important in your life, although not essential, can be helpful. · If you need an interpreter or have any other cultural needs, please notify the clinic when you book/confirm your appointment.

A pain doctor in a multidisciplinary persistent pain service plays a central role in the comprehensive management of chronic or persistent pain. Working alongside other specialists—like physiotherapists, psychologists, and occupational therapists — the pain physician brings medical expertise to diagnose, treat, and manage pain conditions that often have complex, multifactorial causes. Their responsibilities include: 1. Assessment and Diagnosis: Conduct thorough assessments to determine the underlying causes of persistent pain, which will involve taking a detailed medical history, a detailed life history (we try and learn as much about you as possible), sometimes performing physical exams, and ordering imaging studies or lab tests if needed. 2. Medical Management: Develop individualised pain management plans in combination with the rest of the team. Our area of expertise is medication and interventions, but we will encourage physical reactivation and lifestyle change as these are often the most effective treatments. Psychological support is also effective and often essential. We use a range of medications such as analgesics, anti-inflammatory drugs, antidepressants, or anticonvulsants. We also review and adjust these medications to optimise pain control while minimising side effects. We try and avoid long term opiates as evidence shows a worse outcome in persistent pain patients on long term opiates. 3. Interventional Procedures: One of our team can perform targeted interventions such as nerve blocks, inject Botox, or arrange medication infusions. These procedures are not commonly done but can provide significant pain relief for certain conditions and complement other treatment modalities. 4. Coordination with Other Specialists: Collaborate closely with other members of the pain team to ensure a holistic approach. This may involve coordinating with physiotherapists for movement-based therapy, psychologists for cognitive-behavioural interventions, and occupational therapists for support in lifestyle adjustments. Furthermore, coordination with other specialists from outside of the pain team may be needed, such as Orthopaedics or Gynaecology specialists. 5. Patient Education and Self-Management: Educate patients about their condition, helping them understand the complex nature of persistent pain, and help them understand the role of various therapies and lifestyle adjustments in managing persistent pain. We also guide patients in self-management strategies, which are crucial for long-term relief. 6. Monitoring and Outcome Evaluation: Regularly monitor the patient’s progress, adjusting treatment plans based on response and emerging needs. Pain doctors use outcome measures (such as the ePPOc questionnaire) and feedback to ensure that the treatment approach remains effective and in line with the patient’s goals. By combining medical expertise with a collaborative, interdisciplinary approach, pain doctors help patients achieve better pain control, improve functionality, and enhance quality of life in the face of persistent pain.

Physiotherapy at the Persistent Pain Service is guided by the biopsychosocial model, which considers the relationship between physical, emotional, and social factors in understanding and treating pain. Physiotherapists undertake full assessments and treatment planning with patients and aim to improve activity tolerance, confidence, function and quality of life. Patients should expect to learn strategies which enable them to develop self-management of their persisting pain. Core physiotherapy techniques Assessment and diagnosis of musculoskeletal conditions Goal setting Pain Neuroscience Education with a focus on reassurance and education about the thoughts and feelings that may be associated with individuals' pain experience Structured and tailored exercise prescription Graded exposure therapy Sleep education Adjunct physiotherapy techniques (as required) Mobility aid prescription and education Movement pattern re-education Manual therapy or acupuncture, where appropriate TENS (Transcutaneous Electrical Nerve Stimulation) Mindfulness and breathing exercises Graded Motor Imagery (Desensitisation and mirror therapy)

This is a group programme for people who find persistent pain interferes with their ability to lead a normal life. PEP is a six-week programme developed to help you decide what’s important to you, and to support you to take the next best steps towards being yourself again. People attend the programme once a week (9:30am -12:30pm). Each group is limited to 10 people. Although delivered as a group programme, people will have an individualised treatment plan and clear goals that they are working towards. A typical session Consists of education, discussion and feedback from group members, and exercise. Topics explored include understanding pain, managing activity, value identification, sleep, goal setting, and more. Participants are encouraged to contribute to the discussion. Each session includes mindfulness practice. Why do we use a group approach? Persistent pain can be a socially isolating experience with family, friends and even treating medical teams not understanding how difficult it can be or, to put it other words, they just don’t “get it”. In the group you will be able to meet other people in the same boat as you, who are managing pain that hasn’t gone away who are trying to figure out how to live their lives. People who understand what you mean when you say your pain still hasn’t changed. Group programmes also give people the opportunity to share information and learn from one another. Who do we help? The programme aims to help people with: Pain lasting more than three months. No further medical/surgical investigations or treatments planned. Not requiring urgent psychiatric treatment. No primary drug or alcohol problem. Ongoing interference of activities of daily living due to pain. How can the patient education programme help you? PEP may help if pain is interfering with your attempts to maintain normal daily activities or work. You may feel you are managing quite well, but other ideas and strategies may help to continue your improvement. PEP may help you regain control over your life and achieve your goals despite having pain.

iSelf-Help is an online group programme for people who find persistent pain interferes with their ability lead a normal life. It is a 12-week programme developed to help you decide what’s important to you, and to support you to take the next best steps towards being yourself again. People attend the programme twice a week on Mondays and Wednesdays (1:30pm -2:30pm). Mondays are with a peer support facilitator who has a lived experience of persistent pain, and Wednesdays are with clinicians from the persistent pain service. Although delivered as a group programme, people will have an individualised treatment plan and clear goals that they are working towards. A typical session Consists of education, discussion and feedback from group members, and exercise. Topics explored include understanding pain, managing activity, value identification, sleep, goal setting, and more. Participants are encouraged to contribute to the discussion. Each session starts with a review/reflection on previous content. Participants also have access to online resources. Why do we use a group approach? Living with persistent pain can be a socially isolating experience with family, friends and even treating professionals not understanding how difficult it can be or, to put it other words, they just don’t “get it”. In the group you will be able to meet others who are managing pain that hasn’t gone away or hasn’t changed much, who are also trying to figure out how to live their lives. Groups programmes also give people the opportunity to share information and learn from one another. Programme staff Staff have extensive experience in pain management. The team includes a peer facilitator, psychologists, physiotherapists, and occupational therapists. Who do we help? The programme aims to help people with: Pain lasting more than three months. No further medical/surgical investigations or treatments planned. Not requiring urgent psychiatric treatment. No primary drug or alcohol problem. Ongoing interference of activities of daily living due to pain. How can the iSelf-Help education programme help you? It may help if pain is interfering with your attempts to maintain normal daily activities or work. You may feel you are managing quite well, but other ideas and strategies may help to continue your improvement. iSelf-Help may help you regain control over your life and achieve your goals despite having pain. iSelf -Help is targeted to those who cannot travel to Dunedin or take significant time off work during the day to attend the in-person group.

The Persistent Pain Service offers a group exercise class on Friday mornings from 9am to 10am. All participants have an individualised programme that is designed by the physiotherapy team and is tailored to their specific needs and abilities. The supportive environment encourages motivation and accountability, making it easier to maintain a regular routine. Exercising with others can reduce the feelings of isolation that persistent pain can cause through sharing your journey, challenges, and successes. The group setting also allows for the exchange of tips and coping strategies, as members support each other. This blend of personal and collective experiences can boost motivation, improve adherence to exercise routines, and create a positive atmosphere that enhances overall wellbeing.

Numerous studies suggest mindfulness is a key pain coping skill. This 8-week course is for patients who have a basic understanding of mindfulness but would like to better understand how to use it to support their pain management. Members can expect to learn through in-session discussion and practice, and daily home practice.

One of the most difficult parts of coping with chronic pain is its impact on relationships. Being in a group with others who understand the lived experience of having chronic pain can be very useful. In this ongoing weekly ongoing group, members will be invited to engage with each other in a manner that focuses on interpersonal process. This means the group leaders help members use their interactions with each other to learn more about themselves and their interpersonal patterns. Patients often report benefits from the group that extend to their everyday lives and personal relationships.

Mind Retrain Pain Foundation Illustrated by modular explanations about pain & various aspects affected by pain- Chronic pain | Healthify Multiple resources & information on pain management/videos/apps Pain resource: 'Navigating Pain' - New Zealand Pain Society A team of health professionals from the New Zealand Pain Society, including physiotherapists, psychologists, nurses, doctors and occupational therapists have put together this booklet to help you understand what you can do to manage your pain. painTRAINER Is an interactive, online program based on scientific research that teaches you effective strategies to manage your pain. Chronic Pain | Pain Management Network Youth pain bytes, modules of information on common aspects affected by pain, supported by short video presentations. Tame the Beast Education tool that aims to inspire research-based action in the treatment of chronic pain. mycuppajo.com - Joletta Belton - Lived experience advocate Jo Belton - “Making sense of pain through science and stories. Bridging the gap between patients and health professionals.” Pain Self-Management by Pete Moore | The Pain Toolkit The Pain Toolkit is an interactive and simple information booklet, that provides readers or listeners with handy tips and skills to support people along the way to self-managing their pain or long-term health condition. Recovery Strategies The book is designed to help therapists and patients deal with injuries and persistent pain Pain Science Education Podcast with Dr Joe Tatta Mindfulness Apps Self-Compassion by Kristin Neff

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