Understanding and managing chronic pain
Chronic pain – commonly defined as pain that lasts beyond the normal healing time of three to six months – affects one in five Australians aged 45 and over.
Conditions such as osteoporosis, gout, arthritis and musculoskeletal conditions contribute to chronic pain. People with chronic pain also tend to have higher rates of long-term conditions such as cardiovascular disease, diabetes, stroke, and mental health disorders. Chronic pain can negatively impact daily activities and our enjoyment of life.
Managing chronic pain is complex, and the evidence supports an Interdisciplinary Pain Team including a physician, clinical psychologist or psychiatrist and other allied health professionals (physiotherapists, exercise physiologists, nurse, dietitian, occupational therapist etc.). Treatments can be passive (e.g. surgery, injections or massage) or active (e.g. education, therapy and exercise). Choosing a treatment is rarely an either-or decision as active and passive treatments usually work best when combined. This article explores how chronic pain can be managed through pain education, psychological interventions and exercise.
Chronic pain and the brain
Pain is defined as an ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage’. It is the perception of the threat that determines the output of pain, not the tissue damage or threat to the tissues. Pain sensors (nociceptors) tell the brain there is danger. It is then up to the brain to determine if you then feel pain.
People who experience pain after healing display changes in their central nervous system which results in an increased sensitivity to ‘danger’ signals. These changes can be seen via special imaging techniques such as a functional MRI (magnetic resonance image). The longer the pain has been experienced, the more areas ‘light up’ during imaging of the brain, and the better our brains become at producing pain. Whilst this neuroplasticity (i.e. the brain’s ability to change its structure) improves the brain’s ability to produce pain, it is also the way in which chronic pain can be managed.
The way we think about chronic pain
Pain is not only a sensory response to stimuli, but also an emotional and physiological response. The way we perceive, feel, and think about pain also affects our behaviour, which then affects our work, relationships and general well-being. Psychology is the study of human emotions, cognitions, and behaviours, so it makes sense for psychology to play a role in chronic pain management.
Psychotherapy such as Cognitive Behavioural Therapy (CBT) target three main aspects of pain:
- pain catastrophising,
- fear of injury, and
- pain acceptance.
Helpful coping skills learnt in therapy aim to change behaviour and reduce the pain-fear cycle making the pain more manageable. Therapy can also address concurrent mental health issues such as depression, anxiety and stress which are more common in those with chronic pain.
Exercise and pain
Exercise has been shown to improve pain and physical function across a range of conditions including fibromyalgia, osteoarthritis, low back pain and chronic regional pain syndrome.
How does exercise reduce pain? It is generally accepted that exercise makes us stronger and improves endurance and stamina. In exciting new research, pain scientists have identified that during exercise there are powerful mechanisms happening inside our body and in particular our brains. These include exercise-induced analgesia (i.e. acute pain relief post-exercise), the anti-inflammatory effects of exercise and how exercise can help our immune system to reduce pain.
Historically, healthcare practitioners have been reluctant to encourage clients to exercise into pain. But with emerging evidence, this has changed. Researchers have discovered that exercising into pain, that is where pain is allowed or encouraged, offers clinically significant short-term benefit over pain-free exercise. The type of exercise is unimportant, however aerobic exercise and strength training have been shown to be effective for improving pain in a range of conditions.
Daniel Cornish, UQ Healthy Living Exercise Physiologist.
Oriana Yau, UQ Healthy Living Provisional Psychologist.
Rebecca Tweedy, UQ Healthy Living Musculoskeletal Physiotherapist
Butler D, Moseley GL. Explain Pain. Adelaide: NOI Group Publishing, 2013 (2nd Ed)
Brain structure, psychosocial, and physical health in acute and chronic back pain: a UKBioBank study. Tagliaferri SD et al. Pain. 2021 Oct 26.