About Ten Footsteps

“This programme of Ten Footsteps is excellent and yet the old adages 'it’s all in the mind' and 'pull yourself together' still creep in from the patient’s point of view. The most important thing for clinicians is believing in the patient’s pain and there should be more emphasis on this. It’s important because it promotes self-belief. This is – in itself – an empowering tool with regard to self-management.”

An expert patient's view

Welcome to Ten Footsteps, developed ‘by clinicians – for clinicians’ to help you support your patients towards better self-management of their chronic pain.

Persistent pain is a challenge: for the person with pain, their family or carers, their friends, work colleagues and employer – and certainly their clinicians.

Clinicians, especially general practitioners, realise the need to change how they work with people with persistent pain. Relying solely on medication, with its range of side effects and long-term problems, just adds to the challenges.

Persistent pain cannot be ‘fixed or cured’ but there is still much that can be done. Pain scientists have shown that a biopsychosocial approach is more effective in managing chronic pain than the traditional medical model.

This is why Cognitive Behavioural Therapy (CBT), with its ‘five areas’ model of person centred care, is increasingly seen as a useful framework for encouraging patients’ development of self-management skills.

In the 'five areas' model, physical symptoms, moods, thoughts and behaviours all interact with a person's situation or environment to affect how a person experiences their pain.

Self-management is essentially about working on these different areas of one’s life. Patients who have developed self-management skills not only cope better with their pain and lead fuller, more satisfying lives – they tend also to be more effective in their use of health care services.

The way forward for clinicians is to know more about persistent pain and ways to engage patients to help them shift their mindset from “fix it for me” to “help me make the best of my life.”

Ten Footsteps is a resource to help you do just that.

How to use this resource

This resource is divided into ten sections, which we have called ‘footsteps.’ This reflects the fact that, as a clinician, you will be going on a journey with your patient as they first come to terms with, and then learn the skills of, self-managing their pain.

Each of the ten footsteps covers a discrete self-management theme. Each is recognised by clinicians working with chronic pain to be a vital component in the ‘toolkit’ of people who have learnt to manage their pain effectively.

The order of the ten footsteps follows a pattern that has been identified in people learning to self-manage. This is sometimes known as the self-care cycle.

The self-care cycle

The self-care cycle describes the process by which a person first learns more about their condition; then begins to accept it for what it is; develops a plan to do something about it; takes action; encounters setbacks; learns to overcome them; and ultimately comes full circle, recommitting and recommencing their life journey towards living well despite their pain.

Acceptance, for example, is located early (footstep 2), as it is in some ways a prerequisite for embracing the whole idea of self-managing one’s pain.

However, acceptance does not always come all at once, and it would be unproductive to insist on a patient ‘completing’ a footstep before moving on.

So, although the footsteps are arranged in a loosely chronological order, it is important to remember that:

  1. your patient may not embrace the idea of self-management or explore its different dimensions in the precise order that we describe, and
  2. they may want or need to return to certain ‘steps’ more than once, for reinforcement, learning or simply reassurance.

In reality you may find yourself working with your patient on more than one footstep at once, or return to a theme with them if a patient is struggling to integrate it into their life.

This idea of ‘working with’ is key. If your patient is to become an effective self-manager of their pain, their active involvement is absolutely vital. That’s why many of the patient resources included in each footstep can be printed off directly, for you to give to your patient.

When you give a printout to your patient, it’s a good idea to suggest that they share with you what they learn from it at their next appointment. Getting patient ‘buy-in’ to the idea that they will be speaking about the resource at your next consultation is one way to ensure that it actually gets read.

Other patient resources are links to online content, which again you can give to your patient together with a suggestion that they tell you what they think of it at your next appointment.

Some of the links are to videos made with people who have already travelled on the self-management journey themselves. These first person testimonials will inspire your patients – and you.

As you explore these resources with your patients, they will gradually find that a better life, despite the pain, is possible. And by using Ten Footsteps as part of your work with them, you’ll find that it is possible to support patient change in pain self-management, and that – despite the frustrations – it can be interesting, fun, thought provoking and satisfying!

So, take the first footstep…

Each footstep is also contained in a handy PDF so you can download and print it to refer to later:

Need a bit more guidance?

Have a look at this 10 minute video, in which Dr Frances Cole introduces a patient with persistent pain to the concept of pain management...

Getting started

The Health Needs Assessment for Persistent Pain (HNA) is a very useful tool for getting started with your patient, as it helps both you and them to identify the main problems that they themselves feel are most important to improving their quality of life.

For guidance on how to use the HNA, download this article from Live Well with Pain's clinician newsletter:

Download the HNA guidance

Three accessible books that will be useful for your patients

Throughout the Ten Footsteps we have provided links to download and print useful resources related to each footstep.

In addition, the following three books provide a more general introduction the subject of pain self-management. They provide accessible and practical help for people living with pain:

An introduction to Living well with Pain

This self-help guide brings together tools that have worked with thousands of people with pain. It guides you through skills that help you stop struggling and cope well with pain, including:

  • Goal-setting, making action plans and rewarding yourself
  • Pacing your day to day activities and building in relaxation practice
  • Developing healthy exercise and eating routines
  • Sleeping well again
  • Coping with setbacks

Overcoming Chronic Pain 2nd Edition

This easy-to-follow book sets out:

  • Why pain can persist when there's no injury or disease present
  • How to become fitter and pace your activities
  • Practical ways to improve sleep and relaxation
  • Tips for returning to work, study and gaining a life you value

Chronic Pain The Drug-Free Way

Written with humour, and making use of cartoons and line drawings, this book encapsulates 20 years of pain management courses given by Phil Sizer at Pain Association Scotland to patients, GPs, and other health professionals.

Topics include:

  • pacing
  • goal-setting
  • stress management
  • relaxation and sleep
  • dealing with flare-ups
  • coping with unhelpful thinking
  • relationships with others
  • being a person not a condition