Pain Management Concepts

---

Pain grabs our attention like a threat. That is what it is designed to do: alert us to a problem. 

Sometimes the problem is obvious, a broken bone, for example. In this day and age we know what to do about a broken bone and can feel some relaxation in knowing that it can be resolved. We may experience new fear of breaking a bone again which can make us hesitant to engage in activities like we used to. 

Sometimes a problem is not so obvious and we're left trying to figure out why we are receiving this alert signal. Our fear of what might be causing the signal can lead to other fears. For example, we may worry that we will not be able to be the active parent or grandparent that we wanted to be, we may not be able to exercise, we have become undesirable as/to intimate partners, we may not be able to earn a livable wage, our way of life or, worse, life itself is under threat.  

We may act from this place of worry to try to find the answer that seems most plausible for the intensity of our symptoms. We may worry more that if we cannot find appropriate care to resolve the pain that all of the scenarios above, and others, will happen. All of this worry can heighten into anxiety if we feel that we have not received the validation and support from care providers and other people in our lives. 

It all circles around a sense of insecurity about the unknown. We don't know why it is happening. We don't know what to do about it. We don't know why it isn't going away. We don't feel we have over the decisions those involved in our care make, or the timing of care. We don't know if something that causes more pain will worsen or happen again let alone how to stop it.

We don't know. And that's scary.

It can be caused by several different conditions. It can be enhanced by how you feel about it. It can ebb and flow like tides or it can be a constant companion. 

There are several terms we use in clinical settings to define pain so we can better identify what may be contributing to it. Here are some common ones that show just how different pain experiences can be.

Acute pain is the type that has started recently, can come and go, usually has an identifiable cause, and goes away when the cause is resolved.

Chronic/Persistent pain may or may not be associated with a cause, does not go away when the presumed cause is resolved, lasts more than 3-6 months, can be present all the time or come and go, and adversely affects a person’s well-being, function, and quality of life. 

Continuous pain usually lasts for at least half a day.

Flare up pain is a type of pain that arises in a person whose baseline level of pain has been stable.

High-impact chronic pain lasts at least 3 months and has severe impacts on a person’s ability to participate in their daily occupations, such as self-care, employment, and socialization. It is also associated with significantly high levels of: pain, cognitive impairments, mental health challenges, and difficulty with basic self-care.

Its reasons for existing can be more complex than people understand. 

Nociceptive pain is the type of pain we normally think about. An injury has occurred, such as a broken bone or torn rotator cuff. The nervous system communicates that an injury has occurred by sending signals along a sensory pathway to the brain. We call this type of sensation nociception. It is a part of our sensory system just like the big 5 many people learned about as schoolchildren (vision, hearing, smell, taste, touch). The sensation of pain serves a purpose as a protective response so that we don’t injure ourselves further.

Neuropathic pain occurs because of abnormal nerve function. Here the nerves themselves are communicating incorrectly due to chemical imbalance, lesion, or similar. This is often experienced as numbness or ‘pins and needles’ sensations. People with diabetes may experience this condition and management of their blood sugar and inflammation levels may help. Other examples of conditions that can cause neuropathic pain include sciatica, carpal tunnel syndrome, and multiple sclerosis. 

Nociplastic pain is also a type of abnormal nerve signal, however in this instance there is no obvious injury or insult to body parts or nerves. People with fibromyalgia, irritable bowel syndrome, interstitial cystitis, headache, and temporomandibular disorder are described as having this type of pain.

• Nociplastic pain was previously referred to as central pain or central sensitization. You may still hear these terms. It can happen because the nerves that send signals to the brain are hyper-responsive to sensory inputs. It can also happen because the brain does not send an inhibitory signal out to the nerves to calm them down. 
• There are real changes seen in brain scans and some neurochemicals related to this type of pain which validates that this is a real physical experience. It simply does not have an obvious, singular cause.
• The experience can include pain that is more intense than it should be (hyperalgesia) and pain in response to a sensation that should not cause pain (allodynia).
• Research is showing us that people who are experiencing nociplastic pain tend to have combinations of biological, psychological, and sociological vulnerabilities in their past and/or present. These appear to be contributing to heightened states of chronic stress that contribute to chemical and/or epigenetic changes in the body that relate to pain signaling. 
• "Epigenetic" refers to how your environment can alter how a gene expresses itself. It does not change the structure of the gene but change how it behaves. 
• You may also hear the term neuroplastic being used. This is referring to how the nervous system can learn to respond to stimuli. In the case of pain, it refers to how it learns to respond with a pain signal to a sensation that is not painful (allodynia). The good news is that this can be un-learned.

People with pain are often treated as if they can do more than their pain experience will allow. Some people who have dealt with this their whole life may feel adept at accepting this, however most of us tend to turn that attitude inward into our own mental chatter about how well we “should” be able to do something. Please, try to stop “shoulding” on yourself. Instead, endeavor to practice self-awareness and self-acceptance of your experience. "Shoulding" results in increased stress which results in increased pain and, often, poor moods.

Change takes time. It can be difficult to let go of roles that you’re used to doing or even just changing the method by which you do them. Often what we do is tied to our identity and how we do them is tied to an image of ourselves at a different time in our lives. Our ‘what’ and ‘how’ choices can also be tied to our values, such as a work ethic, independence, and helping others. Making a change, then, can feel like changing something important about ourselves. 

Instead, I encourage you to explore your options. Trial the different methods you find in this website and the links to recommended programs. See what you like. Learn how much of it you can tolerate. Take notes for later reference. Practice integrating different methods into your day. 

It is ok for you to try something, stop, and try it again later. Be respectful of yourself as you go through this process. Take your time. These responses are normal.

There are a variety of approaches, exercises, devices, etc. that are recommended for pain management. Not all of them will be for you, however trying some and finding that they are not useful does not mean everything will not be useful. Explore the options. Consider your preferences and what you know about how you tend to do things. Consider your health concerns. Look at the information around an approach. Decide how much or how little you want to try. Do a trial run and see how you respond.

A special note about this idea and exercise. Exercise is very beneficial to pain management. It is considered analgesic (a pain reliever).  You may have been given exercises by a therapist before. If they worked, great! If they did not, or they aggravated pain, this does not mean that there isn't another option for you. Look for other exercises or community programs that get you moving. The more you do this, the more likely you are to develop a plan that fits your needs.

There are times in a therapeutic setting and in the context of certain types of clinical concerns where a therapist will ask you to engage in something that will increase pain and discomfort. Depending upon the type of clinical concern(s) you have, a therapist may also prescribe a home exercise program that causes an increase in pain or discomfort while you do it. However, there are limits to how much of a pain increase is acceptable in these instances. In general, we would prefer NOT to aggravate pain. 

Instead, be effortful but stop your effort at the stage before you are experiencing pain or even before you are experiencing a warning sign of pain. 

This will require you to pay attention to your signals and learn to respect them. We often push through by thinking 'no pain, no gain' or 'I have to get this done.' However pain signals, tend to beget more pain signals which can make you feel worse. It can stop you from doing as much as you might have if you had limited yourself to effort only.

This concept applies to physical movements, psychological efforts, and emotional experiences. 

IF it is necessary to experience some pain in order to begin to move, try to keep the pain increase within 1 to 2 points on the commonly used 10-point rating scale where 10 means the pain is intolerable. If the pain increases and remains increased for 24 hours, then do less next time. Les can mean fewer repetitions, less overall time, a smaller range of motion, etc. 

Attend

We often spend much of our day being led around by the thoughts in the front of our mind. We then haul our body around in order to 'get things done.' We are not paying attention to how this is impacting our health or experience of pain or pain warning signs, or anything, really. 

The single, simplest thing I recommend to people is to spend a moment or two really attending to what you are experiencing when you move a certain way, eat a food or meal, engage in an intellectual pursuit, feel an emotion, etc. You can teach yourself quite a lot about how to manage your concerns based on your preferences simply by attending to how you experience something.

Allow

When you have pain, you may guard the painful area and compensate by overworking other parts of your body. Both guarding and compensation can present as muscular tightness in areas that may not be directly related to the source of the pain. 

You may develop pain in these areas but you may be able to do more with them to relieve that pain. Forcing them to do a movement that feels painful or results in increased tension, though, does not help. Instead, make the effort and stay within your movement tolerance, as described earlier, and allow for your body to relax and go further as it can. 

This same concept also applies to how you feel psychologically. Emotions may arise while practicing exercises and relaxation methods. Be gentle with yourself. Allow the emotion to rise, observe it kindly, and let it pass so it can begin to resolve. Try not to chastise yourself for having the emotional response. This tends to result in the emotion becoming stuck.

CONSIDER: As mentioned at the top, pain can be scary. We usually want to distract ourselves away from it. In general, distraction can be a good tool. However, it also makes sense to pay attention to it as if you are having a conversation with it. I have found that when people ask their painful area 'what's going on?' or 'what do you want me to know?' they learn something important. For example, they may learn that they are holding their worry about a person they care for in that area of their body. They may learn that they feel anger over a recent event. Whatever is identified can then be addressed by journaling, speaking with a counselor, seeking spiritual input, and more. Often, simply being able to express it to another person is enough to acknowledge the issue and relax the pain.