BACK SKILLS TRAINING GROUP SESSION 1

TASK 1. WELCOME AND AGENDA (2-3 MINUTES)

Nametags, housekeeping, can move around, introduce aim of BeST (manage pain better)

TASK 2. PARTICIPANT INTRODUCTIONS (5-7 MINS)

Name, duration of low back pain, main goal
Draw on the flipchart
Course overview & responsibilities of participants
• Use contents table to show topics covered.
Attendees should:
• Attend every session and ask anything they want
• Do the exercises given at initial assessments
• Give activities at least a two-week trial
• Do the weekly homework tasks
TASK 3. DIFFERENT TYPES OF PAIN (20-25 MINUTES)
Draw this table on the flipchart:
Severe pain Severe tissue damage
Moderate pain Moderate tissue damage
Mild pain Mild tissue damage
No pain No tissue damage

EXAMPLES: injured soldiers, migraine, cramps, paper cut, car crash injury, mouth ulcer,
stubbed toe

Highlight:
 Pain useful and necessary
 Acute pain usually identifiable source
 Chronic pain a nuisance – no identifiable source
 Pain persists due to nerve changes:
o nerves become hypersensitive
o pain system like an oversensitive smoke alarm
 Our brain remembers pain
 Amputation and phantom pain supports this
 Pain stops us doing things we enjoy
 Changes can be reversible
TASK 4. PREVIOUS TREATMENTS/SELF-HELP (5-10 MINUTES)
• List different treatments patients have tried on the flipchart

QUESTIONING: What does this tell us about back pain? Should we try all
treatments? Any risk with this? (How do we feel when a treatment fails?) Where do
we strike the balance?
BREAK (10 MINUTES)

TASK 5. LEARNING ABOUT INACTIVITY (15 MINUTES)

Draw this diagram on the
flipchart (fill in purple and blue
sections only)

QUESTIONING: What does

pain do to activity levels?

Ask patients for effects of inactivity and

effects of activity or exercise.

Your table should include:

Effects of Inactivity Effects of Activity or Exercise
Weak muscles Strengthen muscles
Stiff joints and muscles Improved flexibility
Less fit – feel tired More energy
Feel tense - muscles knot up Wind down
Feel fed up Get a natural high – endorphins, bodies own painkiller
Put on weight Lose weight

 Go back to flow diagram and fill in ‘Physical Changes’ (green circle above)
EXPLAIN: This is why exercises and increasing activity levels important
Likely to get aches and pains with exercise
3 types of exercise – stretches, strengthening, fitness

TASK 6. REVIEW OF FITNESS GOAL (10-15 MINUTES)

 Ask patients for progress and problem solve with group

TASK 7. HOMEWORK (5 MINUTES)

 Review other two goals they have ready for next session

TASK 8. FEEDBACK (1-2 MINUTES)

TASK 9. LINK TO NEXT SESSION

 Pain fluctuations, Baseline setting for goals
GROUP SESSION 2

TASK 1. AGENDA (2-3 MINUTES)

Homework will be discussed later in the session

TASK 2. OVER / UNDER ACTIVITY CYCLING (5-10 MINUTES)

• Draw this diagram on flipchart without the red arrows or text initially

HIGH Do less –
pain goes
down

Pain levels

Do more –pain
goes up

LOW
Time

• QUESTIONING – what happens to activity levels when pain is high or when pain is
low?
• Add in red text. Normalise this pattern of doing more when feel good and less when
feel bad
• DISCUSS – this pattern leads to decrease in activity, unable to predict etc

TASK 3. PACING (20-25 MINUTES)

Avoiding peaks and troughs is called pacing

• Systematic approach to changing activity - either to build up or limit over activity

• Balancing activity so that the day is divided into chunks of relative rest and activity
• Pacing also means doing the activity whether feeling good or bad
• Activity levels should not be pain dependent
• Aim to maintain an even level of activity over the day and week
• Can try breaking up activities according to position adopted
• On a bad day - still try to keep going but break up the activities more
• As a group think of an example of an activity that they overdo and use the following
to break it down as a group;
• On flipchart:
Prioritise, Plan, Tolerance level, Evaluate
BREAK (10 MINUTES)

TASK 4. SETTING BASELINES (5-10 MINUTES)

How much of the activity or exercise can be done at the moment without overdoing it
• Review how to set baselines
i 3 measurements
ii Calculate average
iii Set baseline a little below this
Activity

Time

• Draw figure on the flipchart to demonstrate graded activity (10-20% increments every 1-
2 weeks)
• Discuss as a group what to do if pain increases after an increase in activity

TASK 5. GOAL SETTING (10-15 MINUTES)

• Check homework - identifying goals
• On flipchart - using a patient example - review what a goal is
• In group discuss how to break down into achievable steps
TASK 6. GOAL SETTING EXERCISE IN PAIRS (10-15 MINUTES)
• Develop a plan on how they will break down into achievable steps
• Come together as a group to discuss problems
TASK 7. HOMEWORK (1-2 MINUTES)
 Get started on their next goal. Check that patients have a plan in place from the
goal setting in pairs exercise

TASK 8. FEEDBACK (2-3 MINUTES)

TASK 9. LINK TO NEXT SESSION

 Discussing unhelpful thoughts about back pain
GROUP SESSION 3

TASK 1. FEEDBACK ON HOMEWORK (10-15 MINUTES)

• Find out how goal setting went
• Discuss 1 or 2 problems on flipchart
TASK 2. UNHELPFUL THOUGHTS (10-15 MINUTES)
QUESTIONING – Do you ever do anything knowing it will flare you up or felt fed
up and given up?
• We don’t ‘act on impulse’ – the way we think affects the way we feel and
then the way we act
• For example meeting on a corner and the other person late
• Key is different thoughts lead to different feelings
• Unhelpful thoughts lead to unhelpful behaviours
• Similar patterns of thoughts:
Type of thinking
Explanations
errors
Black and White Things seen in black and white categories
Thinking “I’ve had one cube of chocolate, I might as well eat the whole bar”
“If I can’t do it the way I used to I might as well not bother”
“I’ve started so I need to finish”
Catastrophising Exaggerating the importance of errors or problems
“I always get it wrong”
“I can’t cope with the pain anymore”
“If this is what I’m like now – I’ll be in a wheelchair by the time I’m…”
Should / Must I should, I must, I ought to, I have to….
Statements “I should be able to mow the lawn in one go”
“I shouldn’t ever lift”
Jumping to Draw a general conclusion based on limited experience or picking up on
conclusions one aspect of an experience
“Exercise is unpleasant”
“It hurts when I drive other cars”
“They think I’m making it up”
Mental filter Pick up on something that fits with your way of thinking and dismiss or
ignore things that contradict your way of thinking
“White vans are always driven badly”
“Arthritis gets worse over time”
Critical Self Putting yourself down or blaming yourself unfairly
“It’s my fault it went wrong”
“I got myself into these vicious cycles”
“Even my thinking is wrong”

BREAK (10 MINUTES)

TASK 3. CHALLENGING UNHELPFUL THOUGHTS (40-50 MINUTES)
• Explain that this is a useful skill
• Draw up the table below on the flipchart and run through
examples
• Ask group for ‘typical’ thoughts they have about their back

Situation Thought Feeling Behaviour/ Action Answer Back Thought

Wake up with There’s no point, Fed up Spend day in Bed My pain is the same but
pain I’m no better Eat chocolate! I’m doing more I’ll get on
I might as well give top of this like I have
up other thing’s before
In the garden, I should be able to Annoyed Persevere and do I’ll do it in my own time
the lawn needs do this, I used to the whole lawn It doesn’t matter if it
doing do the whole lawn (cause doesn’t get finished today
in one go flare-up)

Explore thought: What is helpful / unhelpful about this thought?

Does it fit into any of the thinking styles?
Elicit answer If not helpful - Can we answer back these thoughts to stop us
back thought: acting on them?

TASK 4. MODEL (5 MINUTES)

On the flipchart add ‘Unhelpful thoughts
and feelings’ into model, discuss how
they can have a direct effect on back
pain by affecting activity levels etc

TASK 5. HOMEWORK (5 MINUTES)

• Have a go at identifying thoughts blank tables in session 3 of patient booklet
TASK 6. FEEDBACK (2 MINUTES)

TASK 7. LINK TO NEXT SESSION

• Looking at specific types of unhelpful thinking and learning about relaxation
GROUP SESSION 4

TASK 1. FEEDBACK ON HOMEWORK (15-20 MINUTES)

• On flipchart draw up thought diary (below) from last week, ask for
examples/problems from homework
• Spend time on this as difficult skill to master

Situation Thought Feeling Behaviour/ Answer Back Thought

Action

TASK 2. AVOIDANCE OF MOVEMENT OR ACTIVITIES (20-25 MINUTES)

• There are typical movements or activities that we avoid when we have back pain
• When we’ve avoided something for a long time, we tend not to go back to doing it
again
ASK GROUP - Since you’ve had back pain, is there any movement or activity that you
find particularly worrying or difficult?
• Write answers on flipchart e.g. bending, twisting, lifting

Use lifting to demonstrate the Fear Avoidance cycle – write on flipchart

 • Emphasise that the pain acts to reinforce the thoughts
• Ask the group – how do we get out of this vicious cycle?
• Problem solve with group
• Remind about baseline setting and consider pacing
• If time – do another example of restarting a feared activity – use a participants
example

BREAK (10 MINUTES)

TASK 3. RELAXATION (5-10 MINUTES)

Tense muscles cause pain – relaxation can help with this
• On flipchart write up what activities participants use to relax
• What are other benefits of relaxation? - tension and stress, high blood
pressure, high cholesterol
• Need to be done when relaxed as good techniques can be done at any time and
any place
• Relaxation is not about being lazy!

TASK 4. RELAXATION PRACTICAL (15 MINUTES)

 Help participants find a comfortable position
 Use your own narrative or the audio recording provided
 Deep breathing
 Stretch / relax muscle relaxation
 Feedback after relaxation exercise

TASK 5. HOMEWORK (5 MINUTES)

Have a go at planning how to restart a feared or avoided activity – homework sheet for this
in their session handout. Will be discussed at beginning of next session

TASK 6. FEEDBACK (2 MINUTES)

TASK 7. LINK TO NEXT SESSION

 Looking at another vicious cycle about the effects of worry about pain and further
relaxation techniques
GROUP SESSION 5

TASK 1. FEEDBACK ON HOMEWORK (10-15 MINUTES)

• Refer back to the avoidance vicious cycle from last session – ask patients to summarise
• Homework restarting activities or movements - ask for examples/problems and problem
solve as a group

TASK 2. RELAXATION FEEDBACK (5-10 MINUTES)

• Discuss with the group the 2 techniques they have tried
TASK 3. EFFECTS OF WORRYING ABOUT PAIN (25-30 MINUTES)
• EXPLAIN – easy to get into vicious cycles with pain
• Different things affect how much pain we feel – to demonstrate talk about
clocks
• Ask if group noticed that clocks seem to tick louder or quieter at times;
when might it seem louder?
On flipchart write up responses e.g.;
Night time Nothing else going on
When I focus on it Time important (appointment)
When I’m ill / stressed When it’s quiet

EXPLAIN – the ticking hasn’t actually got louder or quieter

Ask group – can they make any connections between this and their pain?
Show how this can be drawn up in a vicious cycle on flipchart:
 IT IS VERY IMPORTANT to discuss how the action reinforces the thought
• Ask the group how they can break this vicious cycle
• Group will come up with methods of distraction, find out what works for them
• Write the responses on the flipchart e.g;

Changing activity TENS machine

Use heat / ice pack Do a puzzle / read a book
TV Medication

BREAK (10 MINUTES)

TASK 4. DISCUSS MEDICATION (10-15 MINUTES)

• Refer patients to page 26 of their Workbook
• Types of medication used for pain
• Side effects
• General principles;
 Take full recommended dose
 Take medication regularly when in flare-up i.e. do not wait until pain out of control
 Reduce/stop additional medication when feeling better (discuss with GP)
 Discuss unacceptable side effects with GP
 Remind participants they have this info in their folder

TASK 5. FURTHER RELAXATION TECHNIQUES (15 MINUTES)

• Use audio recording or your own narrative
• Start and finish techniques with some deep breathing
• Visualisation or Imagery (find scene acceptable to all)
• Autogenic relaxation
• Ask group for feedback afterwards

TASK 6. HOMEWORK AND LINK TO FINAL SESSION (5 MINUTES)

In the last session you will be revisiting skills and discussing flare-up plans. Patients need to
make a note of any problems they have had and bring to next session. Also practice the two
new relaxation techniques and record in their relaxation log.

TASK 7. FEEDBACK (2 MINUTES)

GROUP SESSION 6

TASK 1. FEEDBACK ON HOMEWORK (5-10 MINUTES)

• Discuss the relaxation techniques from previous session
TASK 2. COPING WITH FLARE-UPS (35-40 MINUTES)
• To be expected - a normal path of low back pain
• Sometimes obvious cause e.g. overdoing it
• Sometimes no identifiable cause
• Ask group to come up with effective plan for good and bad spells and put
on flipchart. Discuss any inappropriate suggestions.

During good phase During bad phase / flare-up

Progress exercises and goals Carry on
Add new goals Review baseline activity
Reduce medications (with GP) Review medication
Enjoy yourself Set goals
Plan ahead Use relaxation
Stay active Allow personal time
Practice relaxation Identify triggers if possible

BREAK (10 MINUTES)

TASK 3. REVIEW OF SKILLS / SPECIFIC PROBLEMS (30-45 MINUTES)

• Tackle specific problems as a group OR
• Run through skills;
 Pacing and baseline setting
 Goal setting – including restarting avoided activities or movements
 Thought challenging
 Progression of exercises
 Relaxation techniques

TASK 4. DE-BRIEF / GOODBYE

• Provide with any relevant follow-up procedures for your site