Chronic pain is longstanding pain that has persisted for more than three months. If you suffer with this, then you may find the following helpful.
This is based upon the Understanding Pain Programme in cooperation with the Oxford University Back Skills Training (BeST)
Understanding pain
In the early (acute) stages post-injury, pain can be useful to warn us of tissue damage. However, pain isn’t always an accurate indicator of the amount of tissue damage that has taken place.
Example: Soldiers may not release the extent of their injuries until they have left the battlefield. Conversely, a stubbed toe may feel severe, but be fairly harmless.
This is even more true if pain has persisted for more than three months (i.e. become ‘chronic pain’), by which time most of the healing will have taken place
Long-term pain
Pain persists due to:
- Changes in nerves which carry messages about pain to the brain
- Nerves becoming hypersensitive, so even light touch is interpreted as pain
- Our brain causing us to feel pain when we reproduce a previously painful movement, based on its memory of the pain
Pain and the brain
Your brain contains a map representing the body. This map can change as a result of experience.
Example: A professional violinist’s hands will appear larger, meaning that the brain pays greater attention to them.
In chronic pain, the painful area can become larger in the brain and can even take over other areas of the body map, meaning that movement from other body parts can now also result in pain.
The messages the brain receives from the tissues do not say “pain”, but instead our brain receives these messages and decides whether pain is an appropriate response.
All of these changes are reversible, we just need to retrain our pain system. How to do this is explained in the following sections below.
Activity and inactivity
Being stiff or weak directly influences how much activity we do, by making it harder to be active. Having weak muscles and stiff joints will increase pain. However, this is also two-way, as pain can directly inhibit muscle activity.
Pain cycle
When starting or progressing an exercise, you are likely to feel normal aches / pains due to exercise, that are not associated with harm. Doing any physical activity is better than doing none.
Activity cycle
Usually, when you are in pain or having a ‘bad day’, activity levels reduce. Conversely, when you are having less pain or a ‘good day’, activity levels increase (catching up). However, increased activity on better days can often flare up pain, leading to decreased activity the next day. This way of managing our activity levels reinforces the link between activity and pain, leading us to avoid more and more in an attempt to get control over the pain.
In general, we see that the over active / under active cycle leads to a gradual decline in activity levels. Therefore, trying to avoid these peaks and troughs is likely to be helpful. This is called pacing.
Pacing
Pacing can gradually build on what you can presently comfortably achieve, limit over activity and help you manage the day better by keeping to your planned target.
Pacing also means doing the activity whether feeling good or bad, not doing too much or too little. The aim is to maintain an even level of activity over the day and week.
On a good day, you should not wait for the pain to tell you when to stop, but instead you should stick carefully to your plan and avoid overdoing things. On a bad day, you should still try to keep going as planned, but you could break up activities more to make it more manageable.
Example: Cleaning the car
- Prioritise – What must be immediately and what can wait until another time – Dust inside the car and clear out the rubbish because you are giving someone a lift later.
- Plan – Plan activities and think about what order to do things in – Try hoovering the back of the car one day and the front another day.
- Tolerance level – Work out your baseline for each activity to try and find the middle ground between what you would do on a good day and what you would do on a bad day.
- Evaluate – Stick to the plan and re-evaluate after several days – If no problems with dusting and emptying the car of rubbish, next time try hoovering the back seats as well and see how it feels.
Calculating a baseline
Whatever activity you are planning, it is important to work out where to start.
Example: Walking
- Choose the best time of day to walk and select a good place to start
- Walk at your own pace for a sensible period that you feel you can manage
- Record the time / distance walked e.g. 15 minutes
- Repeat again another day and record the time / distance e.g. 20 minutes
- Repeat again on a third day and record the time / distance e.g. 10 minutes
- Your baseline should be slightly below your average (approx. 80%, so multiply by 0.8)
- Calculate the average (add scores together and divide by three) e.g. 15 minutes
Progressing
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This is called ‘graded activity’ and represents an incremental approach to allow physical conditioning to occur. If we have an increase in pain after making a graded increase, we should go back to previous level for a little while longer, or drop down even further, so the increase isn’t quite as much.
Goal setting
A goal should be:
- Achievable
- In a set timescale
- Written down
- Meaningful
- Realistic
- Broken down into small achievable steps
- Rewarded when achieved
If you don’t achieve your goal, learn from this, break the goal down into smaller steps and measure your baseline again
- Specific – “being able to walk to the local post office and back”
- Measurable – be able to monitor progress
- Applicable – something you want to do and will improve your quality of life
Rewarding – this will help with motivation
Timed – ‘when’ is it expected the goals will be achieved (short and long term)
Unhelpful thoughts
When we are faced with a task / situation it is the thoughts we have about the task that produces emotions or feelings, which then determines how we act.
This depends upon our own previous experiences or what we have learned from others.
Unhelpful thoughts impact on our actions and outputs/behaviours. Challenging these thoughts can help to change our approach to activities.
Unhelpful thoughts and feelings can influence all parts of the ongoing pain cycle.
Avoidance of movement or activity
When we have hurt or injured ourselves there seems to be typical movements or activities that cause pain when we do them. As a result, we naturally avoid doing them in the early stages as it hurts too much to ignore it. When we’ve avoided something for a long time, we tend not to go back to doing it again and this can be limiting for us.
Example: Lifting
- Situation – try to lift something and get pain
- Thoughts – I shouldn’t be doing this, I’m going to hurt myself
- Feelings – worried, scared
- Action – avoid lifting
- Result – muscles and joints used for lifting get weak and stiff
The pain you get when you lift something acts to reinforce the thoughts and this vicious cycle is a very normal response to pain. We get out of this vicious cycle by starting to do the activity, e.g. lifting. Think about ways that you could gradually start lifting again. Set your baseline and consider pacing.
Example: You could start with an empty box and doing a few lifts each day, progressing by adding small loads to the box or incrementally increasing the height of the lift / distance the load is carried.
Relaxation
When we’re in pain, we tense up. Tense muscles, in turn, can become uncomfortable / painful. Relaxation techniques help us to relax these muscles, as well as counteracting the side effects of stress. Relaxation can help reduce chronic pain, anxiety, high blood pressure and cholesterol levels.
The best relaxation techniques are those that can be done anytime, anywhere and in any position.
Example: If you were stuck in traffic and could feel your muscles tensing, then you would need to be able to start relaxation techniques in sitting.
The key to succeeding with relaxation techniques is to practice them initially when pain is at a tolerable level, so that when the pain is worse you know the routine and the techniques can be more effective.
Lots of different things can impact on how much pain you feel.
Example: Have you ever noticed that we sometimes seem to notice a clock ticking more loudly? The ticking hasn’t got louder or quieter even though it seems louder or quieter.
This is similar to being more aware of your pain at night when its quiet, dark and there is nothing much else to think about
The ticking also gets louder when we are worried about the time, which would also relate to pain if you are worried about it.
Actions reinforce the thoughts that cause the vicious cycle. We can break this cycle through things like distraction.
Flare-up management
An effective plan for a good spell:
- Progress exercises and goals
- Add new goals
- Reduce medications
- Enjoy yourself
- Plan ahead
- Stay active
- Practice relaxation
An effective plan for a bad spell or flare up:
- Carry on
- Review baseline
- Review medication
- Set goals
- Relaxation
- Allow personal time
- If possible, identify triggers, learn from it and plan for the next time. However, often there is no clear cause.