Tips about Chronic (or 'Persistent') Pain

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Persistent Pain



The goal of Physiotherapy is to reduce the effect your pain has on your life by improving your
function enabling you to DO more.

Improved range of motion, more strength, endurance, flexibility, able to tolerate movement and
activity, better able to take part in your Life.

This is a very difficult phenomenon to explain Ill try to update it as I learn more and add books
and informative video links




Why say Persistent Pain rather than Chronic Pain?



With time, familiarity and use, some words lose their original precision: they can even acquire a meaning
opposite to the original one. The never ending deluge of misinformation from advertising and other media
makes matters worse. Chronic [1] pain means the pain has lasted longer than expected. Its as simple as
that. Many people think chronic means worse, more dangerous, untreatable, more serious,
hopeless or incurable but this is wrong. The word chronic, though originally harmless, now carries
baggage for many patients it can set off a train of unhelpful emotional, cognitive and behavioural
responses (we refer to these as maladaptive responses) that can limit function and even make pain worse.
Helping patients to identify and avoid maladaptive responses is an important part of my job. So is
Mythbusting.





My doctor says I have Persistent Pain. What is Persistent Pain?



Let's deal with acute pain first. Persistent pain is not the same as acute pain.



Acute pain is short-term pain that usually occurs after an injury or during the course of a disease. Acute
pain usually warns us of tissue damage and it usually goes away when the threat to the body subsides.
Acute pain is usually located in or near the injured body part. It can be severe but it can also be mild or
moderate: it can be constant (meaning 24/7) and there can be times when you dont feel it. Acute pain is
easy to explain; it is usually related to trauma and inflammation, but it is NOT always proportional to the
amount of damage or the seriousness of the damage (e.g. you could experience severe, acute pain from a
small amount of damage in a heart attack, almost no pain from a stroke causing brain damage, and
excruciating pain from a small splinter stuck under a fingernail). This pain system isn't very reliable, but it
is vital that we have it (see http://en.wikipedia.org/wiki/Congenital_insensitivity_to_pain).


Think short term when you hear acute.



Persistent Pain

Persistent pain is pain that lasts from 6-12 weeks or more. It can affect a large part of the body and can be
mild, moderate or severe. It can be constant (24/7) or intermittent just like acute pain. The main difference
is that it lasts longer than acute pain.


Think long term pain when you hear persistent pain or chronic pain.



Acute pain is useful in that it usually warns us of tissue damage: the same cannot be said of persistent
pain. It is not possible to predict from the extent of your injuries whether or not your pain is likely to
become persistent later on. Many patients with persistent pain cannot recall being injured at all, and the
source of their pain is a mystery to them. This often causes distress. Some of these patients fear that their
doctor or therapist does not believe they are in pain because the time for normal healing has passed or there
is nothing on their MRI. Others fear they are being labeled a liar, a malingerer or 'mad'. They often feel
that no one understands their pain: they are frustrated because no one seems to be able to explain it. Many
patients with persistent pain worry that they might have a serious disease that no one has discovered yet
such as cancer, an aneurysm or a blood clot. They feel afraid, anxious, distressed and sometimes depressed.
These feelings do not help and they can actually make the pain worse. Pain, and the way we respond to it,
can make it hard to get out and meet other people persistent pain sufferers often feel isolated.



If you believe the human mind cannot affect pain one way or another,
then you dont know the human mind or pain!

Scientists and doctors all over the world are investigating pain. Through this research, the management of
persistent pain is improving.



So, what causes persistent pain?



Persistent pain is difficult to explain it takes time and sometimes the explanations seem to make no sense.
It is frequently necessary to explain the phenomenon of persistent pain numerous times to a patient before
their preconceptions are overcome and they have discarded erroneous and un-scientific information given
them by others.
Mythbusting is hard work

Nerves transmit information by sending signals from one to the other across junctions called synapses. A
signal must be strong enough for it to communicate across the synapse to the next nerve. This is called the
firing threshold. You could picture this threshold as the pressure required to depress a light-switch and
turn on a light. If you don't press the switch hard enough, the switch does not 'flick' and the light does not
go on.


In persistent pain, nerve thresholds are lowered so that light touches, light loads, gentle knocks or even
normal movements cause pain. No damage is done but a signal is sent just the same. The threshold can be
lowered so much that the nerve fires spontaneously and triggers a response in the brain without any
provocation. The phenomenon of lowering thresholds is an example of neuroplasticity the ability of the
nervous system to change in response to experience.



There are several types of neuroplasticity - one is called potentiation. A small signal enters a nerve and
the next nerve acts like an audio amplifier and sends out a large signal. Signals entering the brain and
spinal cord of people with persistent pain often become amplified so that they trigger more intense and
more widespread responses than they would normally. They also communicate with nearby parts of the
brain and trigger responses there this is one reason why patients with persistent pain frequently feel that
their pain is spreading; reaching down their arm or leg, or even to the opposite side of the body to the
original injury. Again, this is not a sign of additional damage and it does NOT mean the damage or the
injury is spreading (and no, you are not imagining it).



Persistent pain can be as challenging to treat as it is to explain. This is partly because the person with
persistent pain has to actively participate so much in his or her own rehabilitation. Without your
participation, your treatment is unlikely to be successful.



I have chronic (persistent) pain and my doctor has prescribed physiotherapy. What is the best way
to use my time in physiotherapy?


You will benefit most if you use your time with the physiotherapist effectively. Your physiotherapist has
specialized skills in functional restoration (or rehabilitation) that no other clinical professional has. We
assess you on your first visit to find the physical causes of your limited function (e.g. poor posture, limited
range of motion, weak or tight muscles, stiff joints). We call these physical impairments. The therapist
designs a program to address these impairments. The goal is to enable you to do as much as you possibly
can to minimize your limitations. We try to return you to your normal level of activity, although this is
not always possible. No other health professional has this level of expertise in functional restoration.



What about pain relief?



Physiotherapy aims to improve your ability to function by reducing physical impairments - by identifying
and removing barriers to normal movement. This means it focuses on improving your mobility, body
alignment, strength, movement patterns, flexibility and endurance. Pain control is very important for your
rehabilitation to enable you to do your exercises and get enough sleep - but it shouldnt be done instead
of rehabilitation. Of course your persistent pain may be reduced by physiotherapy: this happens all the time
but your therapy is more likely to be successful if pain relief is not your only goal in physiotherapy.





This amount of physical training takes time, effort and commitment from you. The physiotherapist may
have some techniques to alleviate your pain (e.g. ice, heat, manipulation, dry needling, stretching) but once
your exercises have been taught to you, it is up to you to do them. This is the most effective use of the
physiotherapists skills and your time.




Physiotherapists can tell you how to avoid increasing your pain and they can advise you on pain
management strategies (see below). You will get the greatest long-term benefit if you participate in a
program of progressive exercises specifically designed for you. Focusing solely on reducing your pain is
not the best way to go you may have been focusing on your pain for months or years. Has it helped?




I dont have much spare time. How much exercise will I need to do?



This varies greatly. You will need to put aside some time for your exercises, every day for the foreseeable
future. Many patients feel they do not have enough time to do daily exercises. You will need to re-arrange
your priorities to leave enough time for your rehabilitation. If you decide your rehabilitation is a priority
then you may have to say no to family members and others who make demands on your time. You may
have to give up some of your favorite TV programs, or do some of your exercises in front of the TV.

Your time in the Physiotherapy clinic is very important but it is only a small part of your overall
program. Most of your rehabilitation is done elsewhere: the local park, at home, in a pool or in a gym.
This is not pleasant news to hear but thats just how it is.




But what happens when I have been discharged from physiotherapy? How will I know what to do?



Therapists often advise patients on how to progress their exercise program in the months after you are
finished your physiotherapy - a large proportion of your time spent at the physiotherapy clinic is spent
listening to the therapist EXPLAINING and TEACHING - this knowledge is important for your long term
recovery. This information is hard to retain so I try to put 'reminders' in the Notes sections and Photo
Albums of my Facebook page.





But if I exercise, I hurt!



Your exercises may temporarily increase your pain (or even give you a new pain). This does not
necessarily mean you have damaged something. Your persistent pain has made your body tissues even
those not involved in any initial injury you might have had - sensitive to movement, physical loading, stress
or to postures that are held for too long. People often experience some aches and pains when they start to
move these sensitive tissues again. Your physiotherapist can advise you on which pains to be concerned
about and which ones you can safely ignore, and can tailor your program to minimize exercise pain.



The most common mistakes are to increase the amount or intensity of exercise too fast or to suddenly
increase your exercises on days when you 'feel good'. This can cause a sudden increase in pain. So you
decide that exercise has damaged you and is a bad idea and reduce your activity further perhaps resolving
never to try exercise again. Physiotherapists use a technique called Pacing to teach patients to increase
the amount and intensity of exercise very gradually over time.




A Friend of mine had the same injury last year and he has no pain now? Why has mine lasted for
years?



This is a very frequently asked question. First of all your friend may have been given the same diagnosis
for his injury but this does not mean he suffered exactly the same injury. Your injury may (or may not)
have been a more extensive. Your friend may not be reporting his problem to you accurately. Recent
research suggests that the circumstances of the injury and even the injured persons physical and
psychological response to the injury affect the pain and long-term recovery. The short answer is that no two
injuries are identical, no two patients react in the same way to an injury, and no two patients respond in the
same way to physiotherapy.





Why hasnt my back healed? It probably HAS!



Patients who have had back pain (for example) for many years often ask why their back injury hasnt
healed. The truth is, it probably has. Within 3 months of any injury, your body has usually completed most
of the repair process. It is common for a body part to remain sensitive long after an injury has been fully
repaired or healed. This sensitivity can spread over a large area of the body and even to the other side of
your body. This does not mean the damage is spreading over your body just the pain. Scientists believe
this happens because of a process called neuroplasticity. Pain and your experience of pain brings about
changes in your central nervous system (brain and spinal cord). How or why this happens, or why some
people are more affected than others is not fully understood.




There was nothing on my X-ray, should I be worried about this?



X-rays, CT scans and MRI scans frequently fail to show the cause of your pain. Often, they only show
normal changes that occur with aging (wear and tear). These normal changes are often given medical
names that sound like serious diseases and many patients worry unnecessarily about them. When x-rays
and scans show nothing, this does not mean something very serious must be wrong with you. It does not
mean there is nothing wrong with you either. Your therapist does not think your pain is less severe (or
imaginary) because your x-rays and scans show nothing or were normal. Surprisingly, when x-rays and
scans do show an abnormality in your spine this does not mean that that abnormality is causing your
pain either. Imaging results are interpreted in the context of the whole clinical picture: the patients age and
health status, previous injuries,their description of traumatic events, previous surgeries and treatments and
soon.


"Nothing on your MRI or x-ray? Good, now let's proceed with your treatment!"



Should I keep doing the exercises?

Lets say you have persistent pain and your doctor sent you to a physiotherapist. But you have noticed
some exercises cause discomfort and some cause some other unpleasant symptoms like tingling, feelings of
numbness in your fingertips for instance.

You have several options to choose from:

Option I
Keep doing the exercises
You could decide to persevere with the program and see if things improve. Remember your tissues are
probably sensitive because you have persistent pain. Your body is probably going to complain when you
first start to exercise thats only natural. You are not likely to do any real harm as long as you are doing
the exercises as you have been taught. New or weird symptoms often go away if you persist with the
program.

What if you ignore the new weird symptoms and just keep doing the exercises your therapist has taught
you? Are you likely to do any damage? How do you know when you really should stop?

If your pain (or weird symptoms) is steadily getting worse as you continue with your exercise sessions
and if you and your therapist have tried some alternative exercises with no success you may need to try
some of the other options suggested below. Sometimes a change in medications, injections, procedures with
a pain specialist, acupuncture or psychological assessment and counseling can help enough to get you back
on track with your exercise program.

Option II
Stop doing physiotherapy
You can stop the exercises and stop going to physiotherapy and hope that your problem will just go away
on its own if you just wait long enough. But think about that. If youve already had this persistent pain for a
long time do you think it is likely to just disappear?

Option III
Stop doing exercises
You could stop the exercises and continue going to physiotherapy for some passive treatments like
ultrasound and electrical stimulation. Unfortunately none of these passive treatments are likely to benefit
you in the long term. None of them will make you stronger, more flexible or improve your endurance.

Option IV
Do different exercises
You can ask your therapist for different exercises sometimes it is possible to find an exercise regime that
achieves the treatment goal without causing any unpleasant feelings butsometimes it isnt! It doesnt
take very long to run out of exercises. In which case, youre back to square one. Many patients just have to
accept that exercise are going to be uncomfortable but ask yourself, what is the AIM of the exercises?

The purpose of most exercises is to improve your ability to MOVE either by improving your range of
motion, strength, co-ordination,endurance or even your bodys ability to tolerate physical stresses many
patients initially find activity aggravates their problem are you going to avoid aggravating your problem
by avoiding movement, possibly for the rest of your life? This is not really an option if you want to have a
normal life. How are you going to get your body used to moving again? How are you going to break that
cycle? And that brings us back ... to exercises.

Option V
Try alternative medicine
Alternative treatments are alternative to mainstream medicine. Alternative treatments are so called
because they have not passed rigorous scientific testing. Once a treatment passes the test of rigorous
scientific trials it isnt alternative any more, its mainstream. Many people have benefited from so-
called alternative approaches.

So another option is to try alternative forms of therapy to see if they help examples are acupuncture,
massage therapy, alternative medicines like homeopathy. All of these have worked on SOME people in the
past. Maybe youll be one of the lucky ones. Personally, I have no problem with these alternative
approaches: if they work for YOU, go for it, but I cannot advise you on which one might work specifically
for you.

Option VI
Go back to your doctor
You can return to your doctor and tell him/her your concerns about the exercise program maybe s(he) can
prescribe some other medication or refer you on to another type of specialist. Many patients with persistent
pain find they quickly run out of places to go the first surgery didnt help then the surgeon said s(he)
didnt think it was a good idea to do a second surgery, the other surgeon agreed with the first, the
rheumatologist said there was nothing s(he) could do for me, the radiologist said theres nothing wrong
with your back, the pain specialist did some injections and they helped for about a week . The patient
ends up back at Physiotherapy, usually for exercises.


So, its really up to you. Exercise may not be the only thing physiotherapists do, but it is the mainstay of
physical rehabilitation for patients with chronic (or persistent) pain. We assess you and identity your
movement problems and physical impairments. Then we design a program aimed at improving them. It
may take a long time for a person with persistent pain to benefit from exercises and even then they may
not benefit the way they WANT (or expected) to benefit.In other words, some may still have pain after
months to years of exercise some may not.


Physiotherapy is aimed at improving function it usually helps your pain if you work at it but not
always.



If you believe the human mind cannot affect pain one way or another,
then you dont know the human mind or pain!




What factors to do with you, your accident, your injury,
your reaction to the injury, your attitudes, your
upbringing, your lifestyle are more likely to affect
your pain?


Here are the Pain Magnifiers:

Anger

Fear

Catastrophizing

Distress

Depression

Blame

History of psychological or physical abuse

Stress

An over-solicitous spouse or partner




Less likely to determine the amount of pain you suffer or how long it lasts:

The amount of injured tissue

The seriousness of the injury

Whether or not the accident was dangerous

What was seen on your x-ray or MRI scan

Your age




Pain Management Tips

There will be times when your pain is worse than at other times. You must take the initiative. It is
important that you act on your pain rather than letting it act on you all the time. Here are some things
you can do for yourself to help manage your pain. You may find one to suit you in the list below. Some
people use a combination of pain management strategies.

i. Painkillers (analgesics). These and other drug treatments are prescribed by your doctor and should be
used according to your doctors directions.

ii. Ice (15 minutes, over the painful body part and placed in a pillowcase or other light fabric to reduce
the possibility of skin damage. Ask your physiotherapist if ice is suitable for you and how to use it safely.

iii. Heat (15-30 minutes, over painful body part. Wrap hot pack in towels to avoid burns).

iv. Gentle stretching of tight muscles. Your physiotherapist can show you how to do this safely.

v. Aerobic activities. Get out of breath for about 20-30 minutes regularly (at least three times per
week, preferably daily). Any aerobic activity will do. Your Physiotherapist can advise you about which
aerobic activity is suitable for you and how to gradually increase the amount of general exercise you do
without aggravating your pain too much. Consult your physician before starting aerobic exercise to ensure
it is safe for you. Why do aerobic exercise?

a) It can increase the feeling of general well being (although you may not feel this way at the start
perseverance usually pays off)
b) You can increase your physical fitness
c) Aerobic exercise helps with weight control if combined with sensible eating
d) Exercise can help correct high blood pressure
e) Exercise releases endorphins (your bodys natural painkillers) into the bloodstream
f) You can improve the performance of your muscles, lungs and heart.

vi Meditation I have some familiarity with mindfulness meditation (see book list) but there are
other types out there. Think of it as mind training. Read about it and come to your own conclusion.Doing
nothing and focusing on your breathing takes more practice and effort than youd expect. Its good for
stress reduction too.

vii TENS unit. (also called TNS) This is an electrical unit that is prescribed by physicians. It is about
the size of a pager and it delivers a mild electric current through small, removable electrodes placed on the
skin. The current has been shown to provide some relief from pain. It does not work on everyone and your
Physiotherapist can show you how to use it. TENS does not cure pain and does not repair injuries. TENS
units can mask pain to a limited degree and allow you to do your exercises and function better or just get
some temporary relief.

viii Relaxation techniques. Go to a trained relaxation therapist or learn a technique from a book, tape
or CD.

ix Massage

x Distraction. Pain does its worst work on you when it has no competition for your
attention. Distraction can help to relieve some of your pain at least in the short term. Hobbies, social
activities, community work, visit family or friends, go to a sports event or movie.

xi Some patients get relief from Yoga, Aromatherapy, Music (listening or playing), Tai Chi, Pilates,
Feldenkrais. We cannot recommend any individual practitioners to you and you should consult your Doctor
and Physiotherapist before taking part in any form of exercise class. You should also confirm that the
practitioner or trainer you choose is properly qualified and certified.

xii Acupuncture. Oriental medicine technique involving inserting fine needles into the skin at
special points to bring about changes in the bodys internal energy balance.



Some Useful Websites

webmd.com article on analgesics: (webmd.com/living_better_content/age/article/1738.51438)

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Useful Books

Full Catastrophe Living Jon Kabat-Zinn PhD

Teach Us To Sit Still Tim Parks


Mans search for Meaning Victor Frankl


The Science of Suffering Patrick Wall

Pain: the gift nobody wants
Paul Brand and Philip Yancey






[1] from Chronos (Ancient Greek:!"#$%&, the personification, or God, of Time)