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. This month UQ Healthy Living looks at understanding pain biology and how can we reduce its impact on our lives.

 

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.

The management of chronic pain is complex, and the evidence supports the involvement of an Interdisciplinary Pain Team including physician, clinical psychologist or psychiatrist and other allied health professionals (physiotherapists, exercise physiologists, nurse, dietician, occupational therapist etc). Treatment options can be broadly categorised as passive (I.e. surgery, injections or massage) or active (I.e. education, psychological input, and/or exercise). Choosing a treatment option is rarely an either-or decision as active and passive treatments typically work best in combination. This article explores how chronic pain can be managed through active engagement in pain education, psychological interventions and exercise.


Chronic pain biology and the brain

Understanding pain biology changes the way people think about pain, reduces its threat and improves long-term management. 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 the normal healing process 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 duration of pain 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 it’s structure) improves the brain’s ability to produce pain, it is also the way in which chronic pain can be managed.


Chronic pain: the psychological lens

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 has consequences in our work, interpersonal interactions and general well-being. If we look at the definition of psychology, which is the study of human emotions, cognitions, and behaviours, it makes sense for psychology to play a role in chronic pain management. The primary goal of psychological treatment is not to reduce pain intensity but to target physical, emotional, social, and occupational functioning.

Psychotherapy such as Cognitive Behavioural Therapy (CBT) target three main aspects of pain:

  1. pain catastrophising,
  2. fear of injury, and
  3. pain acceptance.

Helpful coping skills learnt in therapy aim to change subsequent behaviour and reduce the pain-fear cycle making the pain more manageable. Therapy may be used also to address concurrent mental health issues such as depression, anxiety and stress which are more common in those with chronic pain.


Exercise and pain

Exercise is the cornerstone of modern pain management and 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. Regular exercise shifts the balance of cytokine release from immune cells to more anti-inflammatory and less pro-inflammatory in our muscles and reduces the activity of glial cells in the central nervous system.

Historically, healthcare practitioners have been reluctant to encourage clients to exercise into pain. But with emerging evidence, contemporary approaches have 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.

For those interested in learning more, look out for Chronic Pain presentations at UQHL during 2022

 

Authors
Daniel Cornish, UQ Healthy Living Exercise Physiologist.

Daniel Cornish Exercise Physiologist

Oriana Yau, UQ Healthy Living Provisional Psychologist.

Rebecca Tweedy, UQ Healthy Living Musculoskeletal Physiotherapist

References
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.
www.iasp-pain.org