Chronic Pain & Fibromyalgia
Hurt is not Harm:
1. Pain & Damage
13% or 1 on 8 of the entire Irish population is in chronic pain at any time. Being in pain, acute or longstanding, is among the most common reasons for visiting a G.P. and is certainly the most common problem reason for patients attending musculoskeletal physiotherapists.
Pain itself is extremely complex. In the past it was believed that pain was a clear sign and consequence of trauma or tissue damage. The idea was that the body sent chemical and electrical messages to the brain, producing pain as a warning sign to alert attention to the injured body part and prevent worsening damage. The brain then signalled muscles around the damaged tissues to go into spasm thus preventing movement in the body part, protecting it from further damage.
This body-brain-body pattern above is an excellent adaptation to damage in an acute situation, like in the immediate aftermath of breaking a bone in a bad fall.
The main function of acute pain is to alert us to tissue damage. However damaged tissues invariably heal in standard healing times: skin in 5-7 days, soft tissues in 3-8 weeks, depending on type, bone in 6-12 weeks. As the body heals, pain usually eases away.
However in some cases, often where initial injury is much less than life threatening, pain can sometimes persist long after it should have ended. Chronic pain is defined as longstanding pain for a period of three months or more or frequent episodic pain that may vary in intensity over many months, even years.
The reason for this is not fully understood. In recent years researchers across medicine, science and psychology are now beginning to get a handle on the incredibly complex presentation that is chronic pain. G.P.s, pain consultants, pharmacists, chartered physiotherapists, occupational therapists, clinical psychologists and others are pooling knowledge and expertise to address and assist patients ‘stuck’ in chronic pain.
Some widely observed patterns emerge in studying the effect of persistent pain.
Research from all around the world is coming up with the following two simple pieces of advice to begin the process of actively dealing with and reducing chronic pain.
The first is: “Act as Normal” or MOVE. Normal movement is what the body was used to before the pain came on and what it craves even when in persistent pain. Normal movement places normal strain and stress on tissues.
Movement loss is a common consequence of longstanding pain. The body persists in holding the hurt area as if to prevent further trauma even though the actual tissue trauma may have healed months before. Holding the body part abnormally rigid for too long is in fact detrimental. It places strain on adjacent areas and probably actually sustains pain rather than curing it.
A self strategy to address this is to try looking or listening/ feeling.
Looking involves a mirror. If you can see that you hold the sore area differently to the opposite side, look at and focus clearly on the ‘good’ side. Ask your body to mirror the posture of the ‘good’ side. Watch how this changes your overall posture. Do not think about sensations coming from the side of pain. Instead only dwell on making both sides symmetrical. Try to repeat ‘good’ positioning several times a day, initially in front of a mirror, then as you gain confidence, without the visual clue of the mirror.
The other method is to do exactly the same by monitoring local internal sensations. Again, instead of ‘listening’ to the sensations from the sore area, ‘listen’ or feel the ‘good’ side. Try moving to replicate what is happening on the ‘good’ side. Get your brain used to listening to ‘good’ sensations rather than constantly thinking about the sore area. Repeat this frequently
In either case taking on a new posture causes change. Change is rarely easy. However hurting from good change, from new and normal movement does not mean that you are harming tissues, in fact quite the opposite! Improving movement is crucial in the challenge of reducing chronic pain.
The second simple piece of advice to try to move at the same rate as everyone else. Slow guarded movement seems to be a universal unconscious adaptation to pain. However over time, slower than normal movements add to the problem. Perhaps surprisingly, abnormally slower movements can cause stress to muscles, ligaments and joints, making them more pain sensitive. So watch other people: get up quickly and naturally, walk a little more quickly. Mirror how the 87% of the population move.
Try it. It just might be the first step in dealing with persistent pain.
2. Pain & the Brain
Some of the new knowledge and research areas in chronic pain prove that persistent pain is a complex brain issue. New generation scanners such as PET/ fMRI are showing that chronic pain causes widespread changes within the brain. Research is beginning to challenge old ideas on pain and is beginning to lead to new treatment methods for longstanding pain.
One current explanation for chronic pain compares the pain-flooded brain to a computer with a software virus. If you have ever inadvertently downloaded a virus you know the widespread damage it can do to the computer. Imagine chronic pain in the brain just like a destructive chemical virus in your P.C.
Ongoing pain is partially attributed to changes in chemical concentrations in the brain. These chemicals sensitise the brain to pain messages from any source.
In normal instances, when pain messages arrive from a distant body region, the brain can ‘choose’ to listen to the pain or not. Subconsciously the brain surveys the situation and makes an accurate decision as to the seriousness of the pain in the circumstances. In life-threatening situations such as war, the brain may dampen pain in order to save a life. However this selectivity goes out of kilter in chronic pain. The brain seems to lose this ability to analyse and prioritise pain. Instead all incoming pain messages are given high priority.
A threshold level alters in the brain to decide when and how pain is acknowledged. This threshold is unique to each individual and can go up (so it takes more pain before the brain ‘listens’) or down (the brain becomes more sensitive to a smaller amount of pain). This is thought to explain why people rate apparently similar pain at different levels.
In people experiencing persistent pain researchers believe that the presence of pain over time gradually lowers the threshold at which the brain ‘reads’ both overall levels of pain and any extra pain messages. So despite what you might think, people in pain gradually tolerate less and less pain as they become more sensitised to it.
Knowing this happen offers a huge challenge to those of us who deal with patients in pain. The race is on to develop specific chemical agents, drugs, to reduce pain and raise threshold levels towards those of the painless population. New drugs on the market help some, though one person’s good response may not be the same as the next.
Improved understanding of persistent pain is crucial for pain ridden patients to begin to gain some control of the situation.
Boom Bust Cycles in Chronic Pain:
Also interesting is the effect of mood and physical fitness. Both low mood and being unfit further lower the brain pain threshold level. Getting fitter can be hugely important tool in the fight to beat persistent pain. Often having chronic pain causes individuals to do less and less, especially as a bout of unaccustomed activity like a long walk or even a house spring clean may result in increased pain afterwards. This is called the pain ‘Boom Bust Cycle’: a ‘boom’ of increased activity is followed by a ‘bust’ of inactivity due to pain.
Fear Avoidance or Activity Limitation:
Negative responses from ‘Boom Bust’ can bring on a psychological phenomenon known as ‘Fear Avoidance’ or Self Limitation of Activity. In this case, having experienced the Boom Bust Cycle, not surprisingly the person becomes fearful of adding any more pain, so they begin to self-limit their activities in the hope of preventing pain.
It starts with maybe one limitation such as not walking for longer than an hour on any single occasion, perhaps because pain worsened from a relatively similar activity such as standing at a social event for a long period. The painful brain incorrectly equates both activities as the same, so the individual decides not to walk or stand for so long again. Now walks are cut back to 40 minutes duration.
The another semi-related activity brings on pain, so the person decides to reduce walking or standing time further until gradually no walking is done, to prevent pain. This limiting strategy increasingly seeps into many of life’s daily activities, so that the painful person chooses to do less and less.
Is there any way out of this? The answer is a definite yes. Here’s where professional assistance can really help in terms of improved understanding of how pain works, how to change ‘bad’ movement patterns and activity habits.
Learning how to address fitness in a way that will work for the pain filled individual, breaking down tasks into composite parts and pacing activities are all well proven strategies for improving Quality of Life in this patient group. Chartered Physiotherapists are pain and movement experts and play a vital role in actively addressing how to move better and more. Some physiotherapists have further specialised in the complex area of coping with chronic pain and can assist you break down tasks and thought processes in a manner that allows you take first steps back to a fuller life.
If you experience chronic pain, enlist you own multi-disciplinary team of G.P., pain consultant, Chartered Physiotherapist, pharmacist, psychologist. Make sure they all talk to each other. Go for an active treatment programme is active, not passive.
Make today is the day you draw the line in the sand and start to deal differently with your pain.