Key facts about Persistent Pain and what you can do to manage it
What if pain from an injury stays around for a quite some time? What if that pain stopped you from doing things that are important to you? The good news is, that the more you learn about persistent pain, the more empowered you are to manage it.
Did you know that all pain, no matter what, is produced in the brain? Many people think that pain is produced at the skin or within the affected soft tissue. However, in the world of pain science what we do know if that the primary purpose of pain is to protect us; it tells your body to get moving to get away from potential damage. Pain is defined as a sensory and emotional experience and therefore, how someone reacts in a sensory sense depends on the individual and the situation. An individual’s pain therefore can’t be judged against another person’s pain. If you experience ongoing pain, the good news is you’re not alone. Chronic or persistent pain affects more than 3.6 million Australians and is a leading cause of disability. Ongoing pain can affect an individual’s ability to actively participate in social connections and can have negative effects on mental health, relationships, exercise and capacity to work. Let’s look at how pain works, how persistent pain develops and what we can do about it.
Acute Pain
Acute pain following an ankle sprain
When you first have an injury, acute pain is part of a process that lets your body know that it should start the healing process and in the immediate phase perhaps rest/protect the affected area. This is called nociceptive pain, and you may experience this type of pain suddenly, for example when you roll your ankle. You experience a tightness, pain, tingling sensation or heat around the area of injury. This serves to protect our soft tissue, otherwise we may likely continue running on a sprained ankle. In the early/acute stage of an injury, the body systems that facilitate pain perception ‘wake up’ (this takes place in the brain). In most cases, this usually settles down once the acute inflammatory period reduces.
Persistent Pain; why pain remains
Once an injury has healed, body systems may continue to heighten messages resulting in continued pain. The body has healed as much as it is going to, but the pain remains. Pain can be seen as a loyal friend that protects you when you need it. But when it becomes the overbearing friend who is constantly on the lookout for threats, this is when we start to have a ‘wind up’ of the sympathetic nervous system. A ‘dialed up’ sympathetic nervous system may start as a protective mechanism in the acute phase, however with time, it can develop some unhelpful habits. Persistent pain therefore can be described as unhelpful changes in the nervous system. Ongoing or chronic pain causes changes in the brain so instead of the sensation of pain being useful, pain then becomes maladaptive. The nervous system then responds to normal messages such as touch, cold or movement as if they are dangerous. In everyday settings, the brain may misinterpret threat, and further heighten pain in an ongoing manner. Persistent pain lasts longer than acute pain and does not indicate structural damage, even though it may feel like it. In the past we assumed that this was because we had not healed after an injury, but for most people we now know that this is unlikely. We know that pain doesn’t equal structural damage. Instead, the pain is less to do with injury in our bodies and more to do with our central nervous system (nerves and the brain). In the case of persistent pain, it is the emotional aspect that may largely dictate the level of pain an individual experiences, not the actual structural damage that may or may not have been caused.
Iceberg metaphor of the persistent pain experience
The Downward Spiral
From the outside, it may not appear that someone is experiencing pain as they often don’t have a visible injury. However, research points to a number of factors that an individual can experience when dealing with persistent or ongoing pain. This can be described using the metaphor of an iceberg (see image). Whilst above the water and what others may see on the outside is a healthy, moving body, below the surface can be an array of feelings and emotions that can contribute to the individual’s ongoing pain experience.
Pain can lead to avoiding movement and activity, leading to weakness, stiffness and tiredness, which lead to increased discomfort, sleeplessness and mental health challenges, all of which then in turn add to the pain experience. Although there may not be damage in the body, the body perceives everyday things such as putting on your shoes, or washing the dishes, as dangerous. This is where unconscious stories and beliefs can start to develop such as ‘I can’t walk to the shop because I might get pain. I better not lift that because it might cause a flare up. I can’t go and see my friends because I can’t sit for too long, it may make my pain worse.’ Feelings of being damaged, injured, helpless, broken or in need of ‘fixing’ can play into the spiral. The interconnection of these feelings, stories, sensations and experiences such as anxiety, fatigue and sleeplessness can cascade into a vicious and complex pain cycle. Pain can cause low moods; feelings of isolation and depression and can then in turn increase experiences of pain. There’s no more damage in the body, but because of the pain cycle, your pain and ability to cope with everyday activities can get worse with time.
The rollercoaster of emotions and feelings of not being understood, not having answers and not making progress are all normal. A key component to making progress and regaining control over the downward spiral of pain is to understand what you can do to manage it.
“Pain is a biopsychosocial, consciously lived experience that is influenced by, and in turn influences, every aspect of our being, every aspect of our lives. From our genes to our immune, endocrine, and nervous systems, to our beliefs, thoughts, perceptions, to our movements, emotions and behaviours. All of which happen within the wider world of our families, social systems, cultures and society.”
The importance of safety
The good news is, with increased activity and increased confidence, people can experience less pain, which in turn, leads to further positive changes. Evidence-based research suggests that working with the nervous system is paramount in managing persistent pain. The autonomic nervous system responds to environmental cues to help keep the body safe. For some individuals experiencing ongoing pain, a perceived potential threat can dysregulate their autonomic nervous system if their nervous system is already in a heightened state. The process of unwinding the nervous system begins with helping our parasympathetic nervous system ‘wind down.’
Like any other condition, being aware and observing what triggers stimulate the nervous system can do wonders to being able to manage these cues. Looking at the body’s response to normal environmental cues can help explain why some people experience pain more intensely or are more sensitive to pain than others. Finding ways to deal with environmental cures that the body perceives as dangerous therefore can help improve our experience of pain. Working with Polyvagal Theory has been shown to help control pain by alleviating inflammation and modulating neurons involved in pain pathways. Implementing strategies and tools to help your body and nervous system feel safe and know how to recognise safety is a key element in helping manage ongoing pain. If the body and nervous system can’t recognise safety, it will continue to be ‘on alert;’ always looking for potential danger. The body needs to recognise safety not only physically, but also cognitively and emotionally. Below are some helpful ways to facilitate this.
Helpful strategies
Some strategies to improve self-reliance and enhance your sense of nervous system ‘safety’ include:
Sleep Hygiene- maintaining good sleep practices helps to regulate a variety of systems such as inflammation, cognition and mood. Sleep quality and quantity have effects on the brain and therefore pain perception.
Mindfulness- recognising the stories you tell yourself can be powerful. Check in regularly with fears, stories and beliefs about your body and your pain. Affirming statements such as “I am capable, strong, resilient, adaptable etc,” can be helpful in reframing the stories and statements that often prevail amidst a pain flare.
Exercise- grounding, mind-body practices such as yoga and walking can help the body to regulate the parasympathetic nervous system and reduce the effects of stress and the pain experience. Research shows that yoga in particular serves as an effective pain management strategy to help improve mood, stress management, relaxation and self-efficacy. Yoga has been found to be a long-term strategy for pain management.
Gut health- there is a clear link between gut health, inflammation and persistent pain. Eating a variety of healthy foods to promote the balance of ‘good’ gut bacteria and microbiome can help reduce inflammation to improve pain processes. It is a good idea to seek guidance from a qualified dietitian or nutritionist.
Breathing- low and slow is the way to go. Deep, basal/diaphragmatic breathing helps to modulate physiological processes in the central nervous system. Stimulation of the vagus nerve with deep breathing has been shown to reduce somatic pain sensitivity and increase musculoskeletal pain thresholds in healthy subjects.
Concluding remarks
Pain is a complex experience that encompasses many various factors. Therefore, management of persistent pain requires an integrated, evidence-based approach. Various factors such as nutrition, lifestyle, nervous system regulation through breathwork and mindfulness, exercise and movement practices along with inflammation management can help empower individuals to take control of their ongoing pain. Education is key to becoming empowered so working with a healthcare practitioner who can provide guidance and strategies can be the first step on your journey.
Key points to remember
A negative mindset, fear-avoidance behaviours, negative recovery expectations and poor pain coping behaviours are most strongly associated with persistent pain than is tissue damage
Times of ‘flare-ups’ are more related to changes in activity, stress and mood, rather than structural damage
Persistent pain affects the emotional state and can lead to experiencing feelings of depression, anxiety, anger and fear
The relationship between pain and injury is not clear
Pain can be seen as a loyal friend that protects you when you need it. But when it becomes the overbearing friend who won’t let you do things you once loved, stops you from participating in work and social connections, it may be time to reassess whether the friendship is working for you or not.
Some helpful links about persistent pain:
https://www.youtube.com/watch?v=7eQpRZxXv2g
https://www.youtube.com/watch?v=lCF1_Fs00nM
https://www.painaustralia.org.au/media/blogs
References
Whibley D, AlKandari N, Kristensen K, Barnish M, Rzewuska M, Druce KL, Tang NKY. Sleep and Pain: A Systematic Review of Studies of Mediation. Clin J Pain. 2019 Jun;35(6):544-558. doi: 10.1097/AJP.0000000000000697. PMID: 30829737; PMCID: PMC6504189.
Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. 2013. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK132037/
Frøkjaer JB, Bergmann S, Brock C, Madzak A, Farmer AD, Ellrich J, et al.. Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. Neurogastroenterol Motil. 2016;28(4):592–8. 10.1111/nmo.12760
Shao P, Li H, Jiang J, Guan Y, Chen X, Wang Y. Role of Vagus Nerve Stimulation in the Treatment of Chronic Pain. Neuroimmunomodulation. 2023;30(1):167-183. doi: 10.1159/000531626. Epub 2023 Jun 27. PMID: 37369181; PMCID: PMC10614462.
Pearson, Neil & Sullivan, Marlysa & Prosko, Shelly. (2019). Yoga and Science in Pain Care: treating the person in pain.
Disclaimer: The information provided in this article does not replace individual medical advice. Always seek specific guidance by your medical or healthcare practitioner.
Written by Brigitte Grofski
Brigitte is a physiotherapist and co-director of Back to Bounce Sports Physiotherapy.
