Pain is something we all experience at one time or another. When we’ve stubbed our toes as kids or fallen down stairs as adults, breaking many bones.
But even though the feeling of pain has been in our lives forever, very few of us realise that pain can turn nasty — sucking away our positivity and happiness — and hang around for years or even decades.
Until I started researching this article, I never realised that chronic or persistent pain conditions — those that last for more than three months — are having such a huge impact on people around the world.
– At any one time on the planet, around 20% of people have pain that has persisted for more than 3 months.
– The World Health Organization estimates that as many as 1 in 10 adult individuals are newly diagnosed with chronic pain each year.
– More than 100 million adults suffer persistent pain in the USA, which affects more people than diabetes, heart disease and cancer combined, at a total cost of $560–635 billion each year.
– One in five Australians lives with persistent pain, including adolescents and children. This prevalence rises to one in three people over the age of 65. Persistent pain in Australia was estimated to have an economic cost of $34 billion each year in 2007.
Massive impacts on wellbeing
So millions of people are coping with pain. But what are the effects on every day life? Health professionals are so concerned about persistent pain because of what it means for wellbeing and quality of life.
In the early days of healing after injury or surgery, having less pain is proven to help hospitalised patients with less pain breathe better. That is significant. They also feel less stressed; can rest better, and; experience quicker wound healing.
Over the longer term, pain creeps in to many aspects of health and life. Studies in Europe have found that:
– Between half and two-thirds of pain sufferers are less able or unable to exercise, enjoy normal sleep, perform household chores, attend social activities, drive a car, walk or have sexual relations.
– One in four reported that relationships with family and friends were strained or broken.
– One in three were less able or unable to maintain an independent lifestyle.
– One in five had depression because of pain and 17% suffered so badly that some days they wanted to die.
How is it that so many people around the world suffer from pain and with all the advances in medicine these numbers aren’t going down? I can’t answer that question. The only thing I can say is that pain is common, complex, and arises from a range of different situations. Each person feels is differently and has a different relationship with it.
But there are steps that are proven to improve the painful situation.
The first step to help decrease pain is to increase understanding. Pain experts agree that by gaining knowledge of how pain works will change your relationship with it.
In this podcast interview with Lorimer Moseley, co-author of Explain Pain, he says: “Teaching you how to cope and manage, increases your quality of life but also giving you the knowledge to understand your pain; pain changes its meaning. The wonderful thing about pain is if it changes its meaning it becomes no longer necessary. So, if your pain means your tissue is in danger, you should have pain. But if we can convince you (through a very scientifically grounded, evidence-based process) that your pain means your system is overprotective and doesn’t mean your tissue is in danger… your pain goes away.”
If you’re not in pain, pass this on to a friend who is.
In simple terms, pain is part of survival. It is our protector.
The feeling of pain is generated after a series of things happen. For example, an injured body part senses changes (like chemical, pressure, temperature) that *could* mean danger. And the tissues send signals to the brain.
The brain then interprets these messages and a whole gamut of factors like emotions, past trauma experiences, cultural values, and conscious and subconscious interpretations of what this situation might mean. (For example, loss of income or loss of independence.)
The brain determines the actual feeling of pain and its intensity. Ummm… So not simple at all! And yes, you read that right; the sensation of pain is not actually generated from the injured body part.
The point of pain? An internal signal that makes you (consciously and unconsciously) change your behaviour.
I never realised that there were so many different ways to feel pain before my knee injury. It obviously wasn’t the first time I’d experienced pain. But it was definitely the most intense and scary pain I’d ever felt. I felt stabbing pains, aching pains, tingly pains, stretching pains… the list goes on.
According to health experts, there are three widely-accepted pain types, with a fourth one proposed and being debated. Injury is of course just one situation leading to pain. Other common causes of pain include osteo- and rheumatoid-arthritis, cancer and spinal problems.
Short-term pain: associated with an injury or surgery, is the most common type of pain. It occurs in the acute phase of something happening like a burn, cut or break. This kind of pain is called ‘nociceptive pain’.
Inflammation pain: After the initial injury, the second type of pain called ‘nociceptive inflammatory pain’may appear. Inflammation is normal and is a well-coordinated physiological response that involves a range of chemicals from the blood, immune system and specialised nerve fibres. These chemicals talk to each other to help coordinate tissue repair. There is usually swelling and bruising associated with the injury.
Nerve pain: The third type of pain is ‘neuropathic pain’, which is associated with injury or disease of nerve tissue. Neuropathic pain is often described as burning, shooting, stabbing, prickling, electric shock-like pain, with hypersensitivity to touch, movement, hot and cold and pressure.
Persistent pain can be triggered by all pain types and usually the ‘more simple’ pain ones: the acute and inflammatory.
Immediately after injury, pain will cause you to stop moving or twisting in the way that exacerbates your discomfort. This makes sense but from there it can change…
For some reason or another, the (not-so?) smart brain concludes that you are still threatened and need protecting. What can make you feel like you are threatened and need protecting? In our modern world, not usually attacking tigers but feelings of stress, worry and being under threat (e.g. from that job you’re not enjoying or those bills you have to pay). These feelings of threat and stress join in and mix with pain, ultimately creating a recipe for persistent pain disaster!
At the same time, even though your initial injury may be settling down, because the brain has started looking for alternative ways to move to avoid the feelings of pain this means that often muscles are switched off when they really shouldn’t be. So you will be moving differently and this can then cause more pain… Enter potential downward spiral.
How two people feel about pain is never the same. It makes sense that two people with broken arms may have different amounts of tissue damage or inflammation right? But it’s not that simple. David Butler and Lorimer Mosely, say in their book Explain Pain: “The amount of pain you experience does not necessarily relate to the amount of tissue damage you have sustained”.
Amazingly, there are many stories of people suffering severe injuries, such as war veterans during war or surfers being bitten by sharks, not feeling pain. Apart from physical reasons, like poor circulation (this is not a ‘good’ thing) or having a higher tolerance for pain, some people are simply less sensitive to pain. In simplest terms, their brain subconsciously plays down the pain in its interpretation.
In a paper in the European Spine Journal, researchers say there are five key factors that determine the likelihood of experiencing persistent pain:
– coping strategies
– pain acceptance
– pain tolerance
– anxiety of pain
– fear-avoidance behaviour.
So once you know more about pain and the extent your experience, how can you change your pain situation?
There is no magic pill. The best approach you can take to treat your pain is to learn more about pain and then take action with these four things.
If you can learn to cope and manage to limit the impact of pain day-to-day, you will have an improved life. For example, if you can learn the skill of pacing your day so pain is less, this will help. Over time, this can make a big difference to quality of life. Ready to dive in to four key strategies?
The way you choose to relate to your pain will affect much power it has over you. This is pretty amazing! In an earlier article, I wrote about the many thinking-feeling factors that influence recovery and disability more generally. Our psychology directly affects how we relate to pain. If you’re injured but feel safe and secure or couldn’t care less, your pain will be much less than if you’re freaked out about the situation you’re in.
So what can you do? The first step is to explore how you are coping with your pain. Are you taking an active or passive approach now?
This may seem like an odd question. Multiple studies show that patients who use active coping behaviours are at a lower risk of developing disabling pain than those who are more passive. An example of being passive is giving the responsibility for pain management to others including doctors or family members. Or thinking negative thoughts or feeling like you can’t cope… reducing social activities… telling others it hurts all the time… or praying for it to hurt less.
Side note: Watch out for catastrophic thinking
What I call going down the ‘sh&t! This is bad’ spiral could actually be a hint that you are prone to what professionals call “catastrophic thinking”. It is widely acknowledged that this kind of thinking can be a serious problem. Catastrophic thinking — viewing a situation as much worse than it actually is — is assessed in an objective way (for example, using the Pain Anxiety Symptoms Scale and the Fear Avoidance Beliefs Questionnaire) as it can increase the severity of the pain experience.
If you’re prone to this type of thinking, ask yourself how your parents respond to pain. New research shows that the tendency to catastrophise pain might be biologically inherited. This doesn’t mean though that the way you respond to pain can’t be changed; you’ll just potentially have to work a little harder at learning to control your reaction to pain.
Active coping mindset and behaviours
What are examples of an active coping mindset and behaviours?
– Managing your mindset to try not to feel angry, depressed or anxious.
– Forgetting the pain or distracting yourself from it.
– Keeping busy, working on projects, getting back to work.
– Doing regular exercise.
– Doing things you enjoy and finding pleasure.
As researchers from the Center for Integrative Medicine, University Witten/Herdecke summarise in their paper on adaptive coping strategies for patients with chronic pain: “Apart from effective pain management, a comprehensive approach is needed which enhances the psycho-spiritual well-being, i.e. self-awareness, coping and adjusting effectively with stress, relationships, sense of faith, sense of empowerment and confidence, and living with meaning and hope. Also changing negative illness interpretations and depressive or avoidance coping by means of an intervention and encouraging social support by means of patient support groups may at least improve quality of life.”
I’m a huge fan of exercise, physiotherapy and massage and used these to reduce pain and improve strength, stability and flexibility.
Due to pain, the brain will often try to protect the area by reducing activity in the area that originally triggered the messages. And then the muscles turn off in that area. These turned off muscles are no longer supporting the joints, which can lead to further joint injury or lead to alternative muscles working to stabilise the area and then they often get strained. It can become a downward spiral.
So this brain-led self-protection strategy is actually a bad plan. But all is not lost; we can retrain the neuromuscular pathway, this brain to muscle communication channel, and get back to normal function.
According to Tom Dixon, Senior physiotherapist with Get Active Physiotherapy in Sydney, Australia, pain can stick around for a long time due to this automatic switching off.
“In the case of back pain, the deep stabilising muscles around the lower part of the spine (lumbar spine) are used less when people are in pain and strength starts to deteriorate after three days of pain. Without the motor control a vicious cycle starts causing abnormal movement patterns to develop, leading to more pain, resulting in further weakening and so on,” he says.
“The body as a whole (joints, muscles, tendons, cartilage) works better when we move. From the outset for the majority of injuries (not all), I get people moving their injured area. It’s important to remember at this point, however, that I do not mean that you should push through pain. (Athletes use the philosophy of “no pain, no gain” to indicate progress; this is not relevant for pain management.)
“There will be a way that you can move most body parts even with an injury and more often than not I will encourage people to move only in a pain-free range. With this, you get pain modulation through de-sensitisation of the pain centres of the brain. A reduction of pain improves muscle activity and increases the effectiveness of muscle activation/strengthening exercises. Range of movement are therefore a great adjunct to strengthening exercises,” he says.
Oxycodone, Codeine, Ibuprofen, Indomethacin, Acetaminophen, Diclofenac, Aspirin… You may be prescribed one or a few of these by your doctor. Keeping on top of pain is important, especially in the first few weeks, to maintain quality of life. Drugs stimulate certain parts of the brain to interrupt the pain communication in the nocioceptive system. And this can offer a whole lot of relieve to people who are in agony.
However, the standard “pop a Panadol” may not be the best call to action for everyone, all of the time. There is increasing evidence showing that drugs are failing to help with long-term pain and indeed, in the short-term, the side effects can be more trouble than they’re worth.
For people suffering pain not resulting from an acute injury (for example back pain), rethinking the drugs is actually really important so you can work on other things to get back to pain-free. A recent article, Taking drugs to treat back pain isn’t worth it, highlighted an Australian review of 35 trials involving more than 6,000 patients. It found that non-steroidal anti-inflammatory drugs (NSAIDS) used to treat back pain provide little benefit, but cause side effects.
The researchers and physiotherapists quoted in the article agree that there is no quick fix (AKA that ‘magic pill’) for treating pain. They emphasise the need for education, exercise and changing the way people think about pain.
Scientists and medical professionals understand a lot about pain but what works to reduce pain for one person may not work for another. Here are some more techniques or approaches that you may like to try:
– Diet: Some people find that certain foods exacerbate their pain (for example, migraine sufferers often find wine and cheese trigger attacks). And certain foods are linked to inflammation, which can be at the root of some types of pain. If you’re struggling to keep pain under control, keep a food diary and track your pain levels for a few weeks at least and then start experimenting by dropping out certain foods for a couple of weeks.
– Distraction is a technique that applies to both adults and children. When you’re doing things like a Sudoku or talking with someone, the areas in your brain that process pain are less active. Read more about some research on this here: Parents’ reactions can lessen or worsen pain for injured kids.
– Acupuncture / dry needling: there is some evidence that this works for some people. It may be because the fine needles increase blood flow or interrupt the nerve signals that are being sent up the line. Or it may be that the idea of being poked with a needle releases natural painkillers. It’s worth keeping up with emerging research on this. Cochrane reviews area great resource. In this review: Acupuncture and dry needling for low back pain, the authors conclude: “When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small.”
– Pacing: doing physical activities up to 80% of what you could do on a bad day and then repeating consistently to start getting closer to normal activities again.
– Feldenkrais: a specific type of physical therapy working with neuroplasticity.
– Transcutaneous electrical nerve stimulation (TENS): a therapy that uses low-voltage electrical current or pulses. The current or pulse interrupts the signals from pain nerves and it is very effective for persistent pain management.
– Neuromodulation (also called spinal cord stimulation, or SCS) is a proven therapy to manage persistent pain and improve quality of life.
– Relaxing, meditating and going on retreat: yes please! Bring on the positive feelings!
The main message is don’t get stuck; keep trying to make your pain better so that you can avoid going down a negative spiral.
The evidence is clear that by reducing pain you’ll have a better recovery and you’ll be giving yourself a better chance to get back to thriving not just surviving after your injury.
If your doctor or health and well-being team isn’t listening to you about your pain, find others who are up-to-date with the latest best practice around treating pain.
This is a shortened version of the article originally published at www.recoverfrominjury.com/pain-better-recovery in June, 2017. There is also a downloadable resource kit available.