3 Things You Need to Know About Chronic Pain
Pain has always been one of the most consistent parts of my life. I have a connective tissue disorder that wasn’t diagnosed until age 34. It started manifesting as blinding migraines in first grade and has generated a variety of unpleasant symptoms ever since. I know that having chronic pain doesn’t make me unique. According to the US Department of Health and Human Services, pain is cited as the most common reason that Americans access the healthcare system, it is a major contributor to healthcare costs, and chronic pain is the most frequent source of disability. If chronic pain has been part of your life too, I’m sorry, and I’m sending you a virtual hug, which you’re free to decline if you’d like of course. I totally respect consent.
For years I was kind of afraid to talk about pain. As a kid I learned that if I complained too much about the pain I was experiencing, no one would want to hang out with me. In the hospital after my car hit a telephone pole, I learned that sometimes a genuine expression of agony can be met with frustration or ridicule because apparently some (definitely not all, but still...some) medical professionals feel that pain (particularly that of a female, apparently) isn’t valid. Later on, I was also afraid to talk to my clients about their own pain because I felt that I was incapable of handling it. “If it hurts, don’t do it” was the only advice I’d ever been advised to give, and I had been taught that training a client who is experiencing pain was out of scope of practice for a movement professional. Plus, if I really opened up professionally about how much I had learned personally through my own pain story, then all of my clients would know that I was in varying degrees of discomfort pretty much all the time, and that I've spent a large portion of this journey accumulating diagnoses, collecting prescriptions, piling exercises on top of tension and stress on top of strain, and feeling broken while chasing the many ugly faces of chronic pain through every nook and cranny of my entire existence. What would they think? I’d consulted dozens of therapists who didn’t “fix me”, and none of what I’d studied and practiced had entirely ”fixed me” either, so who the heck was I to think I had anything to say on the subject?
Now, over a decade of study later, I know a bit better. I no longer seek to be ‘fixed’, or to restore any previous state of appearance or ability (for a mini-rant blog post on this subject, visit here), and instead I’m focused on getting acquainted with my new normal. For reasons I’ll explain later, now that I’ve eased up on panicking that I’ll never be fixed every time my pain flares, I’m feeling better both physically and mentally. I’m learning how to optimize my conditions and trusting that opening up about my story will bring me closer to the right people, in the right ways at the right times. I also finally feel like I’m rounding a corner in terms understanding the mechanisms behind my own chronic pain enough to help manage my symptoms, and to help myself show up more often as joyful participant in my everyday life. Yes, I still have occasional days of discomfort waiting for occasional flare ups to pass, but I’m no longer consumed with anxiety about the intensity of sensation indicating some kind of newly developed structural damage or an increase in my future baseline level of impairment. Sure, there are times when all I feel capable of doing is rolling around on my Coregeous® ball, or lying on the floor in a dark room, but there are also lots and lots of times when I’m capable of strength training, playing with my kid, carrying a seemingly infinite number of awkwardly shaped things from the car to the beach, sprinting down the block after a run-away dog, and *almost* doing a push-up. #goals.
So now I’m thinking that if what I’ve learned helps me so much, maybe I should tell you about it a little bit. I was finally moved to action last month when I sent out an email asking what you felt most challenged by (thank you, thank you, thank you for responding!), and overwhelmingly the answer was various forms of chronic pain. The reasons for it varied dramatically, but the underlying issue was clear to see. Chronic pain was keeping you from things like playing with children, hiking through the park, creating beautiful art, getting out of bed in the morning, and staying asleep at night. Just like me! When I realized this I felt something funny happen in my gut, as I found myself simultaneously thinking “Oh heck no, I’m thoroughly unqualified to talk about pain” and “Oh, heck yes! Maybe my background in education, passion for learning, and years of experience in restorative movement and massage therapy, along with decades of experience dealing with chronic pain personally, might all add up to one perspective on this issue that might be helpful for someone else with this issue to hear about.”
I’m no longer afraid to talk about pain. I no longer fear anyone judging me for sharing what I’ve learned, and what I think about this crazy adventure so far. If what i’ve learned can help someone, then maybe who the heck am I not to share what I’ve learned on the subject? I have studied a good bit, and while I’m still not qualified to tell you what you what you should do, I do think that there are some things modern pain science has learned recently that may be helpful for you to know. I am about to put on my “body nerd” glasses, but I promise, this stuff is fascinating. PS: Some of this research is current enough that it hasn’t had time to be added into the core curriculum of many med school programs. This means that if they’re not up on current research, there is a decent chance that your doctor may not know the following. Please do not pop-quiz your medical provider on pain science at your next visit. Please do point them to any quality resources that you find helpful or informative.
Here are three things you need to know about current pain science:
Pain is never just physical.
The pain that you feel does not correlate directly to the tissue damage you have experienced. Yes, you read that right. Go ahead and read it again if you’d like. Old school understanding says that when I step on a nail, pain signals get sent to my brain to alert it to the injured soft tissue. We now know that the, nociceptors (danger sensors) in the area detect noxious stimuli send the alert of possible threat to my brain. My brain observes this nociception coming from the foot, relates it to memories of times I’ve felt something similar (I stepped on a broken snapple bottle once at the beach), the other nails on the floor, and to the overly dramatic safety video I had to watch in middle school shop class, and concludes (nearly instantly) that my body is under threat and initiates a searing pain response in the brain area responsible for sensing the foot. The pain I feel is a response initiated by the brain when it quickly interprets so many sensory inputs to mean that I am under threat in some way.
The end result is the same: I move off of what I’ve stepped on, and my foot hurts. The difference is that we now understand that pain is a message coming from the brain which is designed to protect you from threat, not to inform you that damage has occured. So what? So, safety is priority 1 for your brain, and the more your nervous system thinks you're under threat, whether the perception is accurate or not, the more it turns up the volume on your pain alarms. The determining factors for the pain you feel go far beyond the physical.
Your body sense might be smudgier that you think.
The majority of your pain response happens in your nervous system, and when it lasts longer than a typical acute injury, some funky things can start to happen. Cortical Smudging is one of those funky things, and it happens when the brain areas dedicated to sensing the stimulation of body parts (Sensory Homunculus) and areas dedicated to performing functions (Motor Homunculus) begin overlapping. The two regions of the brain, depicted below, wire together a bit, and the brain becomes a bit blind to the body part. This can make it more challenging to sense the affected part of the body, and to control movement there. Unlike objectively observable tissue damage, this indeed is directly correlated to the pain we experience. A 2017 study on motor control reorganization (cortical smudging) found that it was associated both with the severity and the location of low back pain (Schabrun, 2017).
Want to test your motor control? Stand up tall, ears over ribs over pelvis over heels. Lift your toes. Bravo! Now lift only your big toe, without shifting your weight or inverting your ankle . Are you using finger moments to try to help? Now try to lift the 4 smaller toes, and leave the big toes down. OMG, no? Yeah, we’re all a little smudgy. Don’t worry, it’s not permanent. The brain is always adapting and changing (Doidge 2007). Practice these tootsie articulations for a few months, and there’s a good chance you’ll notice a shift in your ability to differentiate toe to toe. World class dancers, athletes and the like tend to be less smudgy thanks to their lifestyle and dancing. More on that later.
When the brain has trouble sensing and controlling an area, its response is often to increase pain. Want to decrease your pain? Increase your proprioception (your sense of your own body in space). Gentle stimulation (as tolerated) at the sites that are causing pain can give your brain more information and reduce this cortical smudging effect, which can help to lessen the pain in two ways. It gives your brain a boost in proprioception, which helps to turn down the volume on the pain sensation, and it can help to block some of the nociception (danger sensation) simultaneously occurring (Mendell, 2014). Getting a massage, performing self-massage, or practicing closed-chain movements can all be helpful here.
The biomedical model of medicine is out of date.
Many of the doctors treating us now were trained under the biomedical model of medicine, which taught them to look at pain as being solely and directly related to an objectively observable pathology — something like soft-tissue damage that modern tests can pinpoint. This model obviously has tremendous value, and sometimes treating through this lens is entirely effective. The current opioid crisis, however, would suggest that perhaps the biomedical medical model is not quite enough when it comes to our current epidemic of pain. That model, presented with a patient in pain despite negative test results, has very little to offer other than medication, which can improve quality of life, but can also be highly addictive or offer unpleasant side effects.
An expansion of this biomedical lens, called the biopsychosocial medical model, offers a more complete picture that considers the biological, psychological, and social factors at play, as well as the intricate and dynamic interactions between them. Having surgery and taking medications can be life-changing or even life-saving, but they require you to be a patient and to be dependent on your doctor. There is tremendous value and empowerment for folks with chronic pain in being able to embrace the healing capabilities of things like community, music, love, and education. These experiences enable us to wear hats other than ‘patient’, like teacher or parent or partner. They keep us depending on ourselves and our social support structure rather than the biomedical industry, and they leave us feeling far more whole.
There is a lots more going on in the creation of a chronic pain condition than just “getting hurt’” It is never just a physical issue, and there’s more to it than the damage sustained by soft tissues. Your thoughts, emotions, and social influences and environment can contribute to the pain you feel as much as any tissue damage does. This is important to understand because it opens up worlds of new intervention possibilities. They may sound a lot like the same old stuff you’ve always heard, but hey, maybe understanding WHY they work, and the science behind them will help motivate you actually DO the things. And so...here are three things you can do with this information:
Go learn more! It’s good for you!
We the people generally have the capability to learn and understand the most current pain science. Unfortunately, most doctors underestimate that ability in the general population (Moseley 2004). From this, along with the knowledge that it can take quite a while for current research to reach practicing professionals through higher education, we can assume that most chronic pain patients have less education than perhaps they should or could handle on this issue. Meanwhile, in a study looking at the effects of intensive neurophysiology education by trained physical therapists on patients with chronic low back pain, they found that intensive neurophysiology education alone was enough to impact results on Survey of Pain Attitudes (revised) (SOPA(R)), and scores on the Pain Catastrophizing Scale (PCS) (Moseley, 2004).
A better understanding of the mechanisms at work behind the pain you’re experiencing can help you feel better about your pain. Being in worse pain this morning than I was last night doesn’t mean that my soft tissues have sustained further damage, and it doesn’t mean I can’t or won’t feel better by this afternoon. While it’s not 100% of the chronic pain solution, it’s empowering. The more you can come to understand, honor, and respect your body and the way it’s always looking out for you (yes, even when its generating pain sensations), the better. The Institute for Chronic Pain has collected some terrific resources here.
Bring awareness to the psychological influences on your pain.
Monitor your mindset. Your thoughts, like everything else, are governed by nerve impulses. Those individual impulses, repeated over time, have the power to rewire your brain for better or worse. Please do not mistake me here. I am NOT minimizing the felt experience or suggesting “it’s all in your head”. I am saying that neurologically, pain is a sensation that comes from the brain’s interpretation of current circumstances, and that is influenced in part by the psychological and emotional factors at play. Depression often goes hand in hand with chronic pain, and it’s important to do what you can to keep it in check. Research has shown that there are thought processes which have the capacity to maintain a pain state (Moseley 2004). Become aware of your patterns of thought around your pain and make sure you sort out these thought viruses.
What’s a thought virus? It’s a concept introduced in Explain Pain in 2003 by Lorimer Moseley and David Butler that refers to anything that we think, say, or hear repeatedly that is scary or threatening. (Note: this book is generally full of current pain science concepts, explained in layman’s terms, and I strongly recommend it.) Thought viruses might look like:
“The X-ray couldn’t see anything so the problem must be really deep”
“Grandpa Joe had back pain and ended up in a wheelchair”
“I’m not moving because it hurts, and I’m hurting because it’s not moving. It’s a vicious cycle and it’s only going to get worse”
These viruses can create fear and a sense of threat in a brain that is constantly seeking safety. If you’re interested in learning more about this idea, look here for some detailed info.
The point is that by being aware of and addressing the negative thoughts that affect us, we can influence the intensity of pain we experience. There are so many ways that we can unknowingly cultivate the faulty mindset that we are are broken, or jagged, or less than, or doomed to suffer. Mind the media you consume, the beliefs you hold, and the thoughts that you allow to land. I am here to tell you that you are the keeper of your own peace of mind. Seek a sense of safety, and guard it well. If you’d like more strategies on how to influence your mindset, visit my blog post here. It’s written through the lens of breast cancer treatment, but it’s applicable anywhere and it’s a powerful practice.
When you need to, distract yourself. Do not allow yourself to dwell in a pattern of thought that's going round and round like a skipping record. Do something to interrupt it. In the same way that I might try to distract an injured kid with a fun new toy while a cast dries over a broken bone, I will turn on a digital yoga class, open a book I’ve been into, or binge watch half a season of something hilarious to distract myself from thoughts and emotions that aren’t helpful.
Bring awareness to the social influences on your pain.
Find providers and practitioners who resonate with you. It’s important. These people are your allies as you seek to find the solutions and strategies that are most helpful on your quest to feel better in your body. If talking to them makes you feel bad, then they’re working against you, not for you. Hearing words like “degenerative”, “crumbling” or “permanent’”from the provider you have decided to trust with your healthcare can have a significant and not-so-great effect. If you’d rank their bedside manner anywhere below a 3, you may want to rethink the practitioners that you employ. If they’re quick to sanction your disability, and hesitant to provide interventions that will help you to improve daily function, or if they’re a little too heavy on the diagnostic terminology and it makes you start catastrophizing and envisioning yourself in a wheelchair just like old Grandpa Joe... then maybe it’s time to look into seeking care elsewhere. Pay attention to how you’re treated by people who aren’t your medical provider too, and pay attention to how it makes you feel. If you have an overprotective friend or partner (this bunch is usually so well-intentioned, aren’t they?) who emphasizes fear of harm befalling you or focuses on catastrophizing the situation, you may want to talk to them about the high-alert affect their attitude is having on your nervous system. (Moseley 2004)
You were probably taught in youth that once we reach adulthood (around 18-25), our brains are fully formed, and fixed. In my elementary school DARE program I remember being told to avoid drugs and alcohol because they would kill my brain cells, and those don’t grow back. Turns out...they do. Or at least, they can. Again, current research takes a LONG time to reach the higher education curricula that educate our medical care providers. Current neuroscience has confirmed that our brains are in fact neuroplastic (Doidge 2007), always adapting. The neural pathways that deeply engrain our patterns of thought, and of movement, and of behavior, and of speech, and of pain — and of everything else — can be changed. Just like a river that changes over time, slowly but surely you can begin to break away from old patterns, and carve out a new pathway.
Ultimately, when you’re sitting in frustration, thinking, “What can I do to cultivate a better life experience for myself when dealing with chronic pain?” the fortunate answer is “Lots of stuff!” Through experience I’ve learned that there is probably no singular thing that’s going to eradicate your pain entirely, but there are lots of things that can help a little:
Diffuse an essential oil that helps you relax
Call a friend and talk for 20 minutes
Move in simple ways that make you feel strong
Watch a funny movie
Share a hug with someone you trust
Visit a float-spa
Get a massage
Practice self-massage with Roll Model Method Therapy Balls (I had to plug them somewhere)
Turn on music that calms you
Put your feet up for 20 minutes
Try a guided meditation
Change the temperature, lighting, background noise in your environment so that it feels as safe and soft as possible
Visit someone like me who has a basket of tricks and techniques for mindset management and therapeutic movement.
Please don’t ignore these seemingly simple suggestions. It may sound a little granola, but we now know that our thoughts and feelings create biochemical change within us. This stuff is important, and it’s impactful. Worry, sadness, stress, and anger impact the severity of your pain, and so can hope, gratitude, and love. You are not broken. At any age, in any state, there is always a possibility of a positive shift somewhere. Try some of these suggestions. Let me know how it goes. If you have questions, aren’t sure where to begin, or feel like you need support, please reach out. I want to be as efficient and effective as possible in helping you to feel more at home within your skin so I’m setting aside some time in my schedule, getting more tech savvy, and offering a discounted video consultation for anyone who has read this far and would like to contact me to book one.
Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology Moseley L J. Pain, 200(Moseley 2004)…
New Zealand Acute Low Back Pain Guide: Incorporating, The Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain Accident Compensation Corporation (N. Z. ), New Zealand Guidelines Group No publisher, 2003
The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science Doidge N Penguin, 2007
Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain Schabrun SM, Elgueta-Cancino EL, Hodges PW Spine , 2017
A randomized controlled trial of intensive neurophysiology education in chronic low back pain Moseley GL, Nicholas MK, Hodges PW Clin. J. Pain, 2004
The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model McLean SA, Clauw DJ, Abelson JL, Liberzon I Psychosom. Med., 2005
Constructing and Deconstructing the Gate Theory of Pain Mendell LM Pain 2014