Chronic Pain Management
Most injuries should heal in four weeks to a maximum of three months. But for some people pain may persist longer than this time frame becoming what is known as chronic pain. Chronic pain can be a complex condition to have and to treat often involving far more than the original physical injury as pain expands to literally become hardwired into the remainder of their life.
Is Chronic Pain physical or psychological?
All too often people with chronic pain face the view that it is all in ‘their head’. The injury should have healed by now, so what else could it be. Unfortunately this is a very narrow minded view, particularly if a person’s injury has not been treated adequately to begin with.
Furthermore, many people experience secondary deconditioning, postural changes and alterations in movement patterns initially as a result of guarding against pain that subsequently may entrench ongoing injury within the physical symptoms. Finally, there is the question of neurological rewiring that hardwires chronic pain into the system at an unconscious level.
So in treating chronic pain there is still a significant need to assess and treat any residual impact of an injury up your body through traditional physiotherapy.
This may include any of the following:
• Pain management through ice, heat or neurostimulation devises such as the SCENAR unit
• The use of natural anti-bruising and inflammatory interventions
• Muscle stretches and strengthening exercise
• Neural mobilisations techniques
• Soft tissue massage and joint mobilization techniques
• Therapies to address trigger points such as stretch and ice, dry needling and SCENAR
• Supportive and dynamic taping
• Postural education
• Rehabilitation and functional strengthening specific to personal needs.
• Education as how to prevent future reinjury and how to deal with future flare ups.
• Surgical referral in the case it is required.
Postural Pain and Dysfunctional Movement Patterns
With or without injury, poor posture may lead to pain through muscle and joint fatigue. Abnormal static postures may also restrict blood flow to the structures and organs directly and indirectly affected. Chronically poor postures may also eventually shorten muscles and lead to joint deterioration, creating more pain and tension throughout the body. A significant contributor to postural change is excessive weight that alters the alignment of the spine in lying, sitting or standing. However poor posture is not only limited to static positioning, postural control is equally important throughout dynamic movement patterns.
During movements that require the involvement of multiple joints and muscles the order of movement is often significant and incorrect movement patterns may cause over lengthening of muscles, compression of nerves, restricted blood flow, joint deterioration and so forth. In particular injuries often initiate altered movement patterns in an effort to avoid pain, leading to long term changes in our dynamic activity related postures.
Paced reconditioning of the body through cardiovascular and strengthening exercise is an important element in addressing chronic pain. However this is not always easy and requires careful exercise prescription, pacing and daily activity planning to avoid cycles of exercise and burn out. Knowing how to implement such a plan can be a vital part of reversing chronic pain and regaining the energy and vitality you want in life.
An often overlooked factor in chronic pain is the influence of a chronic and misfiring inflammatory response that maintains and inflamed reaction in the area of injury. This can be critical to address as any excess in inflammation means that healing cannot progress through its natural stages. A change in diet along with nutritional supplementation along with some of the treatments listed above can be effective in reconfiguring the inflammatory reaction away from a localized chronic inflammatory response.
Have you ever heard someone say ‘Go lose 10 kilograms’ and you will be in far less pain’. As a physiotherapist and nutritionist this is one of my least favorite comments (only slightly less than ‘it’s all in your head). Most people who are active then suffer an injury.
To heal the body must have the necessary nutrients to regenerate injured tissue. Without adequate nutrition therefore, inadequate healing will occur leading to repeated re-injury. However in the absence of injury the body still requires adequate nutrition otherwise microtrauma may lead to pain that may appear to arise without identifiable cause. We are healing our bodies every day from the trials of normal life, so adequate nutrition must not be overlooked as a cause of persistent musculoskeletal pain. Food components may also have a significant influence (both positively and negatively) over the immune system by regulating the inflammatory response and hence pain.
Systemic Disease and Pain
Various systemic diseases may heighten the pain experience. For instance, autoimmune conditions in which the immune system may attack your own body often underlie people’s pain. These include conditions of inflammatory arthritis (rheumatoid, psoriatic, ankylosing spondylitus etc) in which structures about the joint are not recognised as ‘Self’ by the body, such that the immune system responds against them. Persistent pain without a cause must always be investigated as they may arise from more serious conditions of the body. A more subtle way in which the remainder of the body may influence local pain is through the inflammatory markers that regulate the immune system. A general increase of inflammatory markers in the body due to the presence of other medical conditions may sensitise for pain at the local level. In general the greater the state of inflammation in the body, the more pain that may be felt due to a specific and local inflammatory response to an injury. Fat tissue in the obese often increases the inflammatory markers in the body.
Hormone and Neurotransmitter Balance
The hormonal system regulates the rate at which most other functions are carried out in the body. Any pain in a woman that fluctuates with their regular cycle is likely to be associated with hormonal imbalances. Adrenal exhaustion through a chronic stress response may also be associated with increased susceptibility to chronic pain. As chronic pain is frequently associated with depression an overlap with neurotransmitter and neuro-chemical insufficiency, including the body’s natural hormonal pain relief, the endorphins, and the key regulators of the brain, the serotonin and dopamine based systems, is likely. Regulation of the body’s reflexive functions through the autonomic nervous system is also common.
Many conditions that lead to pain are associated with sleep difficulties. The entire range of sleep stages need to be experienced for health, particularly Stage 4 of Non-REM Sleep. This stage is associated with growth hormone secretion, body regeneration and immune system regulation such that the importance of a good night’s sleep cannot be underestimated. Stage 4 sleep usually occurs if the deepest levels of sleep are achieved in the first sleep cycle (generally the first two hours). Of course sleeplessness also arises as a result of painful states, leading to an ongoing cycle of pain, sleep deprivation and a lack of rejuvenation, leading back to increased pain.
The Development of Neural Rewiring
Your brain (and spinal cord) is changing all of the time, continually rewiring itself in relation to your experiences. And there are few more powerful ways of rewiring the brain than through pain and the subsequent stress and emotional trauma that may come about due to injury. Much of this rewiring can take place without you knowing it, so this aspect of your chronic pain can creep up on you if you allow it and do not initially approach your injury with a healthy and healing attitude.
This rewiring has a articulat powerful impact over pain. Neurological Hypersensitivity and Adaptation Prolonged pain feeds forward onto the neurological system and ultimately leads to both neuro-chemical changes and, most significantly, the restructuring of the nerve endings associated with pain and general sensation. Both of these changes in turn may alter the pain experience such that normal sensations in a previously injured part of the body may be registered as a ‘painful’ experience. Furthermore the areas of reported pain may grow in size without any associated physical trauma.
The Complexity of Chronic Pain
Once neural rewiring takes place, the vast interconnectivity of your brain means that chronic pain can become wired into almost any aspect of your life. Remember that pain is a warning system of danger. Because of this, any aspect of your life that is fearful, stressful or threatening can upregulate your pain sensitivity once the rewiring of pain begins to invade after neurological systems. Where once lower back pain was simply increased by lower back pain, anything that turns you into having a bad day may also increase your back pain. Again, this is not a result of your consciously increasing your pain levels, it is because of the unconscious way your pain experience is networking with the rest of your life.
Psychological, Psycho-Social and Psycho-Spiritual Sensitisation
All aspects of the mind have an influence on the pain experience through their effect on attention. Heightened stress and emotion levels alter the entire human system not only on a psychological but a neurochemical level, changing the pain experience (both positively and negatively). Our interpretation of pain is furthermore influenced by how we rationalise pain through the belief systems we have learnt. Thus educational, social, cultural and spiritual influences all may alter the pain experience, stepping down through the neurotransmitters and hormones of the body to increase or repress what otherwise is taking place at the local level of injury.
The Good News
It some ways, therefore, treating chronic pain becomes a combination of addressing whatever ever physical components continue to aggravate your symptoms through traditional injury rehabilitation as well as turning your attention away from restrictive pain related thoughts (known as cognitive behaviours). But it also means managing your stress, your emotions, your thoughts and anything else that may be feeding into your chronic pain.
Yet put in another light, it is also about addressing those aspects of your life that will make you happier, more relaxed and passionate in life, for when you feel nurtured your mind and body’s focus is not on the dangers and stressors that are firing into your pain experience.
Dealing with the wider issues of Chronic Pain
Once you understand the nature of chronic pain a diversity of approaches may be considered to help you overcome it. It is important to understand within this paradigm that no one treatment is likely to be the answer, rather it is the accumulative effect of therapies and lifestyle interventions that will ultimately add together to slowly reduce your pain and rewire your nervous system away from the spiral of the chronic pain path.
Indeed if you have chronic pain it is unlikely (although not impossible) that single magic bullet will be 100% effective, rather you are looking for numerous 5 and 10% effective approaches that add up to you effectively over coming or, in the least, effectively living with chronic disease.
So in addition to the therapies listed above to address the physical factors that may be contributing to chronic pain, pain management may also include:
• SCENAR for neuroadaptive stimulation encouraging rewiring
• A change in your beliefs and attitudes to chronic pain
• Relaxation, visualization and/or self-hypnosis
• Mindfulness techniques
• Discovering new Motivations and ways of overcoming your Fears and Obstacles
• Stress management including therapies such as Heartmath
• Planning to engage in Pleasurable activities that allow for distraction
• Altering your Daily Living Timetable to cope with Chronic Pain
• Mindbody Exercises such as Yoga and Tai chi
• Emotional Intelligence education
• Learning new life skills such as Acceptance, Gratitude
• Psychological interventions
If you are looking to address chronic pain, please feel welcome to make an appointment for physiotherapy and nutrition at Beach Street Centre.