Tips About Chronic Pain

8/12/2019 Tips About Chronic Pain

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Tips about Chronic (or 'Persistent') Pain

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Persistent Pain

The goal of Physiotherapy is to reduce the effect your pain has on your life by improving your

function enabling you to DO more.

Improved range of motion, more strength, endurance, flexibility, able to tolerate movement and

activity, better able to take part in your Life.

This is a very difficult phenomenon to explain Ill try to update it as I learn more and add books

and informative video links

Why say Persistent Pain rather than Chronic Pain?

With time, familiarity and use, some words lose their original precision: they can even acquire a meaning

opposite to the original one. The never ending deluge of misinformation from advertising and other media

makes matters worse. Chronic [1]pain means the pain has lasted longer than expected. Its as simple as

that. Many people think chronic means worse, more dangerous, untreatable, more serious,

hopeless or incurable but this is wrong. The word chronic, though originally harmless, now carries

baggage for many patients it can set off a train of unhelpful emotional, cognitive and behavioural

responses (we refer to these as maladaptive responses) that can limit function and even make pain worse.Helping patients to identify and avoid maladaptive responses is an important part of my job. So is

Mythbusting.

My doctor says I have Persistent Pain. What is Persistent Pain?

Let's deal with acute pain first. Persistent pain is notthe same as acutepain.

Acute pain is short-term pain that usually occurs after an injury or during the course of a disease. Acute

pain usually warns us of tissue damage and it usually goes away when the threat to the body subsides.

Acute pain is usually located in or near the injured body part. It can be severe but it can also be mild or

moderate: it can be constant (meaning 24/7) and there can be times when you dont feel it. Acute pain is

easy to explain; it is usually related to trauma and inflammation, but it is NOT always proportional to the

amount of damage or the seriousness of the damage (e.g. you could experience severe, acute pain from a


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small amount of damage in a heart attack, almost no pain from a stroke causing brain damage, and

excruciating pain from a small splinter stuck under a fingernail). This pain system isn't very reliable, but it

is vital that we have it (see http://en.wikipedia.org/wiki/Congenital_insensitivity_to_pain).

Think short term when you hear acute.

Persistent Pain

Persistent pain is pain that lasts from 6-12 weeksor more. It can affect a large part of the body and can be

mild, moderate or severe. It can be constant (24/7) or intermittent just like acute pain. The main difference

is that it lasts longer than acute pain.

Think long term pain when you hear persistent pain or chronic pain.

Acute pain is useful in that it usuallywarns us of tissue damage: the same cannot be said of persistent

pain. It is not possible to predict from the extent of your injuries whether or not your pain is likely to

become persistent later on. Many patients with persistent pain cannot recall being injured at all, and the

source of their pain is a mystery to them. This often causes distress. Some of these patients fear that their

doctor or therapist does not believe they are in pain because the time for normal healing has passed or there

is nothing on their MRI. Others fear they are being labeled a liar, a malingerer or 'mad'. They often feel

that no one understands their pain: they are frustrated because no one seems to be able to explain it. Many

patients with persistent pain worry that they might have a serious disease that no one has discovered yet

such as cancer, an aneurysm or a blood clot. They feel afraid, anxious, distressed and sometimes depressed.

These feelings do not help and they can actually make the pain worse. Pain, and the way we respond to it,

can make it hard to get out and meet other people persistent pain sufferers often feel isolated.

If you believe the human mind cannot affect pain one way or another,

then you dont know the human mind or pain!

Scientists and doctors all over the world are investigating pain. Through this research, the management of

persistent pain is improving.

So, what causes persistent pain?

Persistent pain is difficult to explain it takes time and sometimes the explanations seem to make no sense.

It is frequently necessary to explain the phenomenon of persistent pain numerous times to a patient before

their preconceptions are overcome and they have discarded erroneous and un-scientific information given

them by others.

Mythbusting is hard work


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Nerves transmit information by sending signals from one to the other across junctions called synapses. A

signal must be strong enough for it to communicate across the synapse to the next nerve. This is called the

firing threshold. You could picture this threshold as the pressure required to depress a light-switch and

turn on a light. If you don't press the switch hard enough, the switch does not 'flick' and the light does not

go on.

In persistent pain, nerve thresholds are lowered so that light touches, light loads, gentle knocks or even

normal movements cause pain. No damage is done but a signal is sent just the same. The threshold can be

lowered so much that the nerve fires spontaneously and triggers a response in the brain without any

provocation. The phenomenon of lowering thresholds is an example of neuroplasticity the ability of the

nervous system to change in response to experience.

There are several types of neuroplasticity - one is calledpotentiation. A small signal enters a nerve and

the next nerve acts like an audio amplifier and sends out a large signal. Signals entering the brain and

spinal cord of people with persistent pain often become amplified so that they trigger more intense and

more widespread responses than they would normally. They also communicate with nearby parts of the

brain and trigger responses there this is one reason why patients with persistent painfrequently feel that

their pain is spreading; reaching down their arm or leg, or even to the opposite side of the body to the

original injury. Again, this is not a sign of additional damage and it does NOT mean the damage or the

injury is spreading (and no, you are not imagining it).

Persistent pain can be as challenging to treat as it is to explain. This is partly because the person with

persistent pain has to actively participateso much in his or her own rehabilitation. Without your

participation, your treatment is unlikely to be successful.

I have chronic (persistent) pain and my doctor has prescribed physiotherapy. What is the best wayto use my time in physiotherapy?

You will benefit most if you use your time with the physiotherapist effectively. Your physiotherapist has

specialized skills infunctional restoration (or rehabilitation) that no other clinical professional has. We

assess you on your first visit to find the physical causes of your limited function (e.g. poor posture, limited

range of motion, weak or tight muscles, stiff joints). We call thesephysicalimpairments. The therapist

designs a program to address these impairments. The goal is to enableyou to do as much as you possibly

can to minimize your limitations. We try to return you to your normal level of activity, although this is

not always possible. No other health professional has this level of expertise in functional restoration.

What about pain relief?

Physiotherapy aims to improve your ability to function by reducing physical impairments - by identifying

and removing barriers to normal movement. This means it focuses on improving your mobility, body

alignment, strength, movement patterns, flexibility and endurance. Pain control is very important for your

rehabilitation to enable you to do your exercises and get enough sleep - but it shouldnt be done instead

of rehabilitation. Of course your persistent pain maybe reduced by physiotherapy: this happens all the time


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but your therapy is more likely to be successful if pain relief is not your onlygoal in physiotherapy.

This amount of physical training takes time, effort and commitment from you. The physiotherapist may

have some techniques to alleviate your pain (e.g. ice, heat, manipulation, dry needling, stretching) but once

your exercises have been taught to you, it is up to you to do them. This is the most effective use of the

physiotherapists skills and your time.

Physiotherapists can tell you how to avoid increasing your pain and they can advise you on pain

management strategies (see below). You will get the greatest long-term benefit if you participate in a

program of progressive exercises specifically designed for you. Focusing solelyon reducing your pain is

not the best way to go you may have been focusing on your pain for months or years. Has it helped?

I dont have much spare time. How much exercise will I need to do?

This varies greatly. You will need to put aside some time for your exercises, every day for the foreseeable

future. Many patients feel they do not have enough time to do daily exercises. You will need to re-arrange

your priorities to leave enough time for your rehabilitation. If you decide your rehabilitation is a priority

then you may have to say no to family members and others who make demands on your time. You may

have to give up some of your favorite TV programs, or do some of your exercises in front of the TV.

Your time in the Physiotherapy clinic is very important but it is only a small part of your overall

program. Most of your rehabilitation is done elsewhere: the local park, at home, in a pool or in a gym.This is not pleasant news to hear but thats just how it is.

But what happens when I have been discharged from physiotherapy? How will I know what to do?

Therapists often advise patients on how to progress their exercise program in the months after you are

finished your physiotherapy - a large proportion of your time spent at the physiotherapy clinic is spent

listening to the therapist EXPLAINING and TEACHING - this knowledge is important for your long term

recovery. This information is hard to retain so I try to put 'reminders' in the Notes sections and PhotoAlbums of my Facebook page.

But if I exercise, I hurt!


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Your exercises may temporarily increase your pain (or even give you a new pain). This does not

necessarily mean you have damaged something. Your persistent pain has made your body tissues even

those not involved in any initial injury you might have had - sensitiveto movement, physical loading, stress

or to postures that are held for too long. People often experience some aches and pains when they start to

move these sensitive tissues again. Your physiotherapist can advise you on which pains to be concerned

about and which ones you can safely ignore, and can tailor your program to minimize exercise pain.

The most common mistakesare to increase the amount or intensity of exercise too fast or to suddenly

increase your exercises on days when you 'feel good'. This can cause a sudden increase in pain. So you

decide that exercise has damaged you and is a bad idea and reduce your activity further perhaps resolving

never to try exercise again. Physiotherapists use a technique called Pacing to teach patients to increase

the amount and intensity of exercise very gradually over time.

A Friend of mine had the same injury last year and he has no pain now? Why has mine lasted for

years?

This is a very frequently asked question. First of all your friend may have been given the same diagnosis

for his injury but this does not mean he suffered exactly the same injury. Your injury may (or may not)

have been a more extensive. Your friend may not be reporting his problem to you accurately. Recent

research suggests that the circumstances of the injury and even the injured persons physical and

psychological response to the injury affect the pain and long-term recovery. The short answer is that no two

injuries are identical, no two patients react in the same way to an injury, and no two patients respond in the

same way to physiotherapy.

Why hasnt my back healed?It probably HAS!

Patients who have had back pain (for example) for many years often ask why their back injury hasnt

healed. The truth is, it probably has. Within 3 months of any injury, your body has usually completed most

of the repair process. It is common for a body part to remain sensitive long after an injury has been fully

repaired or healed. This sensitivity can spread over a large area of the body and even to the other side of

your body. This does not mean the damageis spreading over your body just the pain. Scientists believe

this happens because of a process called neuroplasticity . Pain and your experience of pain brings about

changes in your central nervous system (brain and spinal cord). How or why this happens, or why somepeople are more affected than others is not fully understood.

There was nothing on my X-ray, should I be worried about this?


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X-rays, CT scans and MRI scans frequentlyfail to show the cause of your pain. Often, they only show

normal changes that occur with aging (wear and tear). These normal changes are often given medical

names that soundlike serious diseases and many patients worry unnecessarily about them. When x-rays

and scans show nothing, this does notmean something very serious must be wrong with you. It does not

mean there is nothing wrong with you either. Your therapist does not think your pain is less severe (or

imaginary) because your x-rays and scans show nothing or were normal. Surprisingly, when x-rays and

scans doshow an abnormality in your spine this does notmean that that abnormality is causing your

pain either. Imaging results are interpreted in the context of the whole clinical picture: the patients age and

health status, previous injuries,their description of traumatic events, previous surgeries and treatments and

soon.

"Nothing on your MRI or x-ray? Good, now let's proceed with your treatment!"

Should I keep doing the exercises?

Lets say you have persistent painand your doctor sent you to a physiotherapist. But you have noticed

some exercises cause discomfort and some cause some other unpleasant symptoms like tingling, feelings of

numbness in your fingertips for instance.

You have several options to choose from:

Option IKeep doing the exercises

You could decide to persevere with the program and see if things improve. Remember your tissues are

probably sensitive because you have persistent pain. Your body is probably going to complain when you

first start to exercise thats only natural. You are not likely to do any real harm as long as you are doing

the exercises as you have been taught. New or weird symptoms often go away if you persist with the

program.

What if you ignore the new weird symptoms and just keep doing the exercises your therapist has taughtyou? Are you likely to do any damage? How do you know when you really shouldstop?

If your pain (or weird symptoms) is steadily getting worse as you continue with your exercise sessions

andif you and your therapist have tried some alternative exercises with no success you may need to try

some of the other options suggested below. Sometimes a change in medications, injections, procedures with

a pain specialist, acupuncture or psychological assessment and counseling can help enough to get you back

on track with your exercise program.

Option IIStop doing physiotherapy

You can stop the exercises and stopgoing to physiotherapy and hope that your problem will just go away

on its own if you just wait long enough. But think about that. If youve already had this persistent pain for a

long time do you think it is likely to just disappear?

Option IIIStop doing exercises

You could stop the exercises and continuegoing to physiotherapy for some passive treatments like

ultrasound and electrical stimulation. Unfortunately none of these passive treatments are likely to benefit

you in the long term. None of them will make you stronger, more flexible or improve your endurance.

Option IVDo different exercises


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You can ask your therapist for different exercises sometimes it ispossible to find an exercise regime that

achieves the treatment goal without causing any unpleasant feelings butsometimes it isnt! It doesnt

take very long to run out of exercises. In which case, youre back to square one. Many patients just have to

accept that exercise are going to be uncomfortable but ask yourself, what is the AIMof the exercises?

The purpose of most exercises is to improve your ability to MOVE either by improving your range of

motion, strength, co-ordination,endurance or even your bodys ability to tolerate physical stresses manypatients initially find activity aggravates their problem are you going to avoid aggravating your problem

by avoiding movement, possibly for the rest of your life? This is not really an option if you want to have a

normal life. How are you going to get your body used to moving again? How are you going to break that

cycle? And that brings us back ... to exercises.

Option VTry alternative medicine

Alternative treatments are alternative to mainstream medicine. Alternative treatments are so called

because they have not passed rigorous scientific testing. Once a treatment passes the test of rigorous

scientific trials it isnt alternative any more, its mainstream. Many people have benefited from so-

called alternative approaches.

So another option is to try alternative forms of therapy to see if they help examples are acupuncture,

massage therapy, alternative medicines like homeopathy. All of these have worked on SOME people in the

past. Maybe youll be one of the lucky ones. Personally, I have no problem with these alternative

approaches: if they work for YOU, go for it, but I cannot advise you on which one might work specifically

for you.

Option VIGo back to your doctor

You can return to your doctor and tell him/her your concerns about the exercise program maybe s(he) can

prescribe some other medication or refer you on to another type of specialist. Many patients with persistent

pain find they quickly run out of places to go the first surgery didnt help then the surgeon said s(he)

didnt think it was a good idea to do a second surgery, the other surgeon agreed with the first, the

rheumatologist said there was nothing s(he) could do for me, the radiologist said theres nothing wrong

with your back, the pain specialist did some injections and they helped for about a week . The patient

ends up back at Physiotherapy, usually for exercises.

So, its really up to you. Exercise may not be the only thing physiotherapists do, but it is the mainstay of

physical rehabilitation for patients with chronic (or persistent) pain. We assess you and identity your

movement problems and physical impairments. Then we design a program aimed at improving them. It

may take a long time for a person with persistent pain to benefit from exercises and even then they may

not benefit the way they WANT(or expected) to benefit.In other words, some may still have pain after

months to years of exercise some may not.

Physiotherapy is aimed at improving function it usually helps your pain if you work at it but not

always.

If you believe the human mind cannot affect pain one way or another,

then you dont know the human mind or pain!


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What factors to do with you, your accident, your injury,

your reaction to the injury, your attitudes, your

upbringing, your lifestyle are more likely to affect

your pain?

Here are the Pain Magnifiers:

Anger

Fear

Catastrophizing

Distress

Depression

Blame

History of psychological or physical abuse

Stress

An over-solicitous spouse or partner

Less likely to determine the amount of pain you suffer or how long it lasts:

The amount of injured tissue

The seriousness of the injury

Whether or not the accident was dangerous

What was seen on your x-ray or MRI scan

Your age


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Pain Management TipsThere will be times when your pain is worse than at other times. You must take the initiative. It is

important that you act on your pain rather than letting it act on you all the time. Here are some things

you can do for yourself to help manage your pain. You may find one to suit you in the list below. Some

people use a combination of pain management strategies.

i. Painkillers(analgesics). These and other drug treatments are prescribed by your doctor and should be

used according to your doctors directions.

ii. Ice(15 minutes, over the painful body part and placed in a pillowcase or other light fabric to reduce

the possibility of skin damage. Ask your physiotherapist if ice is suitable for you and how to use it safely.

iii. Heat(15-30 minutes, over painful body part. Wrap hot pack in towels to avoid burns).

iv. Gentle stretchingof tight muscles. Your physiotherapist can show you how to do this safely.

v. Aerobic activities. Get out of breath for about 20-30 minutes regularly (at least three times per

week, preferably daily). Any aerobic activity will do. Your Physiotherapist can advise you about whichaerobic activity is suitable for you and how to gradually increase the amount of general exercise you do

without aggravating your pain too much. Consult your physician before starting aerobic exercise to ensure

it is safe for you. Why do aerobic exercise?

a) It can increase the feeling of general well being (although you may not feel this way at the start

perseverance usually pays off)

b) You can increase your physical fitness

c) Aerobic exercise helps with weight control if combined with sensible eating

d) Exercise can help correct high blood pressure

e) Exercise releases endorphins (your bodys natural painkillers) into the bloodstream

f) You can improve the performance of your muscles, lungs and heart.

vi Meditation I have some familiarity with mindfulness meditation (see book list) but there areother types out there. Think of it as mind training. Read about it and come to your own conclusion.Doing

nothing and focusing on your breathing takes more practice and effort than youd expect. Its good for

stress reduction too.

vii TENS unit. (also called TNS) This is an electrical unit that is prescribed by physicians. It is about

the size of a pager and it delivers a mild electric current through small, removable electrodes placed on the

skin. The current has been shown to provide some relief from pain. It does not work on everyone and your

Physiotherapist can show you how to use it. TENS does not cure pain and does not repair injuries. TENS

units can mask pain to a limited degree and allow you to do your exercises and function better or just get

some temporary relief.

viii Relaxation techniques. Go to a trained relaxation therapist or learn a technique from a book, tape

or CD.

ix Massage

x Distraction. Pain does its worst work on you when it has no competition for your

attention. Distraction can help to relieve some of your pain at least in the short term. Hobbies, social

activities, community work, visit family or friends, go to a sports event or movie.

xi Some patients get relief from Yoga, Aromatherapy, Music (listening or playing), Tai Chi, Pilates,

Feldenkrais. We cannot recommend any individual practitioners to you and you should consult your Doctor


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and Physiotherapist before taking part in any form of exercise class. You should also confirm that the

practitioner or trainer you choose is properly qualified and certified.

xii Acupuncture. Oriental medicine technique involving inserting fine needles into the skin at

special points to bring about changes in the bodys internal energy balance.

Some Useful Websites

webmd.com article on analgesics: (webmd.com/living_better_content/age/article/1738.51438)

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Useful Books

Full Catastrophe Living Jon Kabat-Zinn PhD

Teach Us To Sit Still Tim Parks

Mans search for Meaning Victor Frankl

The Science of Suffering Patrick Wall

Pain: the gift nobody wants

Paul Brand and Philip Yancey

[1]from Chronos (Ancient Greek:!"#$%&, the personification, or God, of Time)

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Tips About Chronic Pain