Persistent Pain

Pain, pain, pain.

The vast majority of the patients I see (if not all of them) attend our clinic because they are in pain. Typically, following an injury, a trauma, a surgery or pains happening in a specific context, situation or environment. 

A lot of the time, there is a structural cause to the pain and everything is straightforward: we manage or promote healing, move things again, strengthen things again… Good to go.

But sometimes, pain can continue to drag on forever and just won’t go away. It keeps coming back out of the blue and keeps influencing us physically, mentally and functionally.
That’s what we call… (brace yourselves) chronic pain. I always joke around the term “chronics” a bit because often people think that the term is a measure of severity, or that it describes a more advanced or incurable condition,  “something they have to live with”. “Ooh I’m getting fierce chronic!” I heard a patient say about his arthritic knee recently…

Nowadays we actually prefer the term “persistent”, which has been shown to carry less of a doomsday feel; for chronic pain is by definition simply a pain that recurs in time, or one that exists for more than 3 months.

The problem with persistent pain is that sometimes patients might have been told “there is nothing wrong with them”, even after multiple appointments, scans and treatment of all sorts. Sometimes patients can even be given a plausible cause, receive treatment for it and still live in pain. The intervention is declared failed and people feel they’re back to square one.This is confusing, frustrating and disheartening for most, as one can feel there is no way out or no solutions. Things can easily snowball.

The truth about persistent pain is that it is complex by nature but it is not necessarily a sentence. It is just a different beast that needs different treatment approaches.

What is persistent pain

Interestingly, you have to view persistent pain more about a nervous system sensitivity than it is about a tissue issue. It is key to understand how this works so let me be clear here: it is possible to feel pain in the absence of an active injury. Things can be sore without being injured, damaged, ill or diseased.

Think of a smoke alarm in your kitchen that would go off as soon as there is a draft in the house. Nothing is on fire, there is no danger there, but the alarm will continue to do its job: inform you about a potential threat. The important word is potential. If the alarm system could see things from an outside perspective, it would not blare off at a draft. But for the smoke alarm itself, a draft or smoke is the same thing at that point and it will make sure you hear it.

So the way we treat persistent pain is very much finding new perspectives and considering all variables that contribute to the nervous system to remain alarmed in the absence of a fire. We defuse or diffuse the signals that the brain manages in order to reduce the amount of pain that it produces. We fine tune the sensitivity of the smoke alarm.

Now, I am not saying the pain is “in our heads”, as in psychologically. Rather, psychological stress is certainly not helping the brain to be calm. And often times, persistent pain causes stress rather than the other way around! So what is very much sitting in our heads is our pain-producing organ brain! Which means that each time you feel pain, it is always real; it is physiological. Tissues and various structures can be sore for being strained, for carrying tension or being weak. These sensations can be made worse with movements and actions but various forms of stress can also make this sensitivity worse.

How can persistent pain be managed?

So first, let’s not talk about “fixing things up”. Because very often, nothing is broken. If the house is definitely not on fire - always worth checking first. When that’s out of the way, we can begin to address the reasons why the brain is over-producing pain.

The first tool is education. This blog is one way to provide that. In the clinic, we assess and re-assess, we clarify, we explain, we discuss, we exchange ideas… dare I say we brainstorm. It is crucial to put people at the center of the discussion and to understand their unique context, history and environment. We then agree on a roadmap, a plan of action with strategies to calm down the nervous system. 

On paper, it is easy. But most of the time, we’re offering to accompany people on a journey, where the final destination is not necessarily what matters, but how to get there is. You’ve heard this somewhere else before I’m sure…

Secondly, we look at lifestyle foundations. Think sleep, nutrition and stress. All can contribute to modulating how the nervous system behaves and reacts. We try to provide a calm and smooth terrain for the brain to operate. We seed better habits to sow comfort and ease.

Third, we ensure that movement and exercise take an important part of the recovery process. We now know that manual therapy, massages, mobilisations (passive process) can help to appease tensions, guide and facilitate movements and provide tactile feedback. Unfortunately, they are not amazing tools to address persistent pain; it can feel nice on the spot though does not carry lasting benefits. Exercise is very useful to maintain the function of the affected area, teaches the nervous system that the body is not injured and soothes it in time. Exercise is also very good for general health and mental health aspects, so it is the (pun intended) no -brainer part of the equation. Motion is lotion, rest is rust. Use it or lose it… Pick the catch phrase that speaks to you the most.

Fourth, sometimes people benefit from introducing cognitive and emotional health management tools. Being in pain for a prolonged period of time can be a burden, affect mood, performance and impact social interactions. Improving coping strategies is a skill worth looking into and can help build up resilience, patience and give people a heightened sense of control and direction.

What to expect moving forward

When I’m explaining the general strategy to patients, I start by explaining how the brain works using what I call the “green arrows / red arrows system”. Have a look at the graph below. Think of the red arrows to be any unpleasant or potentially threatening signals. And think of the green arrows to be the pleasurable ones, the nice ones, the soothing ones. Think of the volume button on the radio: too loud and even Lyric FM can sound overpowering. But a heavy rock song won't irritate you too much if the volume is low. Pain production can be modulated.

On the scale, too many “red arrows” signals and your brain will be more sensitised, more prone to create pain, and have an increased sensitivity threshold. But with a lot of “green arrows”, the brain will be kept “quiet” and in a happy place and won’t fire up nearly as much. Get rid of the red arrows as much as possible, and pump up the green ones. Keep the balance in the green for long enough and you have yourself a retrained nervous system. That’s the aim of the game. 

List of green arrows:

• A nice walk

• Going to a show, comedy club, cinema

• Read a good book

• Spend time with friends and family

• A nice holiday

• (insert anything that feels or is nice here)

List of red arrows:

• Long hours in work

• Stress at home

• Poor sleep

• Financial struggles

• Limited social interactions / loneliness

• Anxious or depressed thoughts

• (insert anything that feels of is not nice here)

Try this little experiment to understand how context and situation can influence our nervous system:

Remember that the brain is in charge of producing pain - among other things of course. So the organ brain receives signals and produces signals all the time and it decides if any particular situation is worth informing its owner (you) of a potential threat. If perceived threat there is indeed - and again the key word is perceived -  then pain can be produced. 

I want you to visualise how your body will feel walking down a deep forest in the thick of the winter late at night. You can’t see your own hands, you’re cold and alone. An owl in the distance, wind in the branches… Creaks in the woods… Do you see where I’m getting at? Right now you may be on high alert.

Now imagine the same spot, same forest, only it’s the next morning, you can see a lovely sunset, nature is waking up, the birds are churping… How does your body feel now? Quite different I’d say.

But were you in any danger the night before? Is it not objectively the same forest? Truth is the main difference is perception. You can’t see in the dark.

To continue on the analogy, what persistent pain management is also about, is to bring a pal with you and to carry a bright torch. You’d feel immediately safer.

In conclusion, the general intention of Pain Management (as it is called in the scientific literature nowadays) is to retrain the brain. As you can see now, this can be a bit tricky and requires time, dedication and patience (or even more patience). Sometimes, it requires creativity, flexibility (the metaphysical kind) and adaptability, for no two days or weeks are ever the same. Having short, mid and long term goals also helps to maintain the general course. Finally, being surrounded by a strong team of clinicians, supportive friends and family members is also important, the load is always easier to carry when shared. 

Specialist Physiotherapists can occupy a central place in assisting people manage persistent pain. 

At Renu, We will listen to your story and understand how your pain affects you in your everyday life.  We will explain and help you understand the reason for your pain and how we can help you control and resolve symptoms so you can better function.

Understand. Recover . Move better 

Do not hesitate to contact us with any questions you may have, we are here to help.