We all experience acute, short-term pain as a response to tissue damage; once the tissues heal, we expect the pain to go away. When the pain persists for more than 3-6 months (the expected healing time after an injury or illness), we define it as chronic pain.
Chronic pain is a widespread and complex condition affecting one in five Australians aged over 45 years old. It is often associated with comorbidities such as depression and anxiety. Individuals with chronic pain are at a higher risk of developing further complications such as opioid misuse, functional decline (reduced mobility leading to muscle weakness and joint stiffness), insomnia/ fatigue, cognitive decline, increased risk of cardiovascular incidents and increased mortality. Chronic pain can also have a severe impact on quality of life, as the social isolation and impact on one’s ability to work can also lead to financial strain and stress.
What causes chronic pain?
Chronic pain occurs when there is dysfunction or an altered pathway in how our body regulates pain. It can be difficult to assess, identify or classify. While it can be related to underlying musculoskeletal conditions, chronic diseases, or post-surgery, in some cases, there may be no known physical cause. When someone experiences chronic pain, their pain threshold can be reduced, pain signalling pathways overloaded, or the pathways that inhibit their pain signals are impaired. Dealing with long-term pain can cause the nervous system to become hypersensitive, which results in individuals experiencing more intense pain from normal stimuli. In addition to this, factors such as anxiety, depression, fear, inflammation from chronic diseases or sleep disruption are all associated with exacerbating the chronic pain cycle and keeping the nervous system in an overactive state. Sleep disruption, in particular, contributes to ‘brain-fog’, lower energy levels, which then further lowers one’s pain threshold.
The Pain Cycle and how to break it!
The chronic pain cycle is a vicious loop where pain can instil anxiety and fear of movement, leading to reduced activity. This increases joint stiffness, muscle weakness and stress, thereby ultimately worsening the pain experienced. So, the cycle repeats with the psychological impacts exponentially compounding as time goes by. One of the most common patterns perpetuating this cycle is often referred to as the ‘Boom and Bust’ trap, where an individual overdoes activity on a ‘good’ day, resulting in increased pain, fatigue and forced immobility over the following days. This reinforces the message to the brain that movement and activity = more pain.
What can a physiotherapist do?
A physiotherapist will first focus on understanding your current activity levels, aggravating movements and then identify strategies on how to ‘re-train the brain’ and reduce the nervous system’s sensitivity.  As the brain begins to interpret the pain signals as less threatening, physiotherapy treatment shifts to returning to baseline activity levels and improving strength/ endurance.
Strategies that may be employed by physiotherapists include:
- Pain reprocessing therapy (PRT): where the assumption is that our brains are stuck in protection mode, and the goal is for clients to re-interpret harmless neural signals as safe and not dangerous. Key principles of PRT include pain neuroscience education (that the pain is not due to an active injury, rather due to a learned response from the brain), somatic tracking (a mindfulness technique where one experience pain sensations with awareness and curiosity, instead of fear or anxiety which worsens the perception of pain), exposure therapy (slow and gradual reintroduction of previously avoided movements to prove to the brain that those actions are safe), emotional regulation (exploring emotional stresses that may be contributing to the pain), and cognitive restructuring (challenging negative thought patterns related to the pain to influence the pain response in a more positive way).
- Stress management: Mindfulness, deep breathing exercises, yoga and meditation can also aid in calming the nervous system.
- Graded activity: Beginning with achievable movements that do not reproduce pain sensations and slowly building up strength and energy. Exercises can range from gentle movement/ stretching, massage, to strengthening, aerobic conditioning (such as walking or using the stationary bike), to functional rehabilitation- returning to baseline activity levels through movement retraining with the goal of reducing fear of movement.
- Pacing: To avoid the aforementioned ‘boom and bust’ cycle, maintaining a consistent level of exercise must be prioritised so as to avoid post-activity severe pain or fatigue.
- Active and passive pain relief treatments: Manual therapy, heat/ cold therapy, TENS, Dry needling/ acupuncture
- Sleep: Discussion on how to achieve and maintain sleep in order to assist with energy levels
Due to the complexities of chronic pain and its associated psychological and emotional symptoms, treatment must be approached holistically, with a multidisciplinary team and person-centred approach. A combination of pharmacological and non-pharmacological interventions is also necessary to support the healing process, as oftentimes management is focused on functional recovery instead of pain elimination.
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