Pain education has many health benefits. Research shows that understanding what pain is and how it works changes the way you think about pain, improves your mobility, and even reduces your pain. These benefits are greater when education is combined with other strategies for managing pain.
- There is no cure for chronic pain.
- The goal of chronic pain treatment is learning how to manage your pain to improve your quality of life
- Surgery and medication may be helpful for some people, but practicing strategies to retrain the pain system, such as pacing activity and reducing stress are also very important.
- Learning how to manage your pain can begins with education and finding the right strategies that work for you is an ongoing journey.
“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
- International Association for the Study of Pain
Many of you would agree pain is a nuisance, undesirable, and something to avoid. What you may forget are the benefits of having pain.
Pain has a purpose – to protect you from danger or harm.
- Pain is normal and an important part of the body’s warning system.
- The amount of pain you experience does not directly relate to the severity of injury
- Pain protects you from danger or harm
- By being unpleasant, pain makes you think differently, behave differently, and move differently.
- It makes you react in ways that protect you when you are hurt or before you are hurt badly.
The human body as a house and pain as a smoke alarm. If the alarm goes off, your natural reaction is to look for fire in the house. If the fire is small or there is little smoke, you may try to fight the fire. If the fire is big or there is lots of smoke, you will likely call for help. Like a smoke alarm, pain warns you of potential danger and makes you take action.
- Pain is a normal response that warns us against danger
- Metaphor: pain is a smoke alarm in your body that warns you of danger (fire).
What is happening in the body?
Say you step on glass...how do you feel pain?
- Scattered all over the body are millions of nociceptors (“danger” sensors) that are constantly surveying its environment.
- These sensors are everywhere – in the nerves inside your skin, muscles, bones, and even your brain. Sensors can be specialized.
- Some react to mechanical forces like pinching or pressure- such as the sharp force from glass. Others react to temperature, and others to stress hormones, immune chemicals released when you are sick, or the slowing down of blood flow around your tissues.
- Nociceptors are constantly detecting stimuli from our environment, our brains filter out this information and we only notice signals that are important to us.
Up to the Brain
- Nociceptors send signals that travel along the peripheral nerve fibers, up the spinal cord, and to the brain.
- The peripheral nerve releases chemical messengers (neurotransmitters) that tell the spinal cord nerves what to do.
- These chemicals fit into receptors on the spinal cord nerve and tell the spinal cord to send this message by electrical signal up to the brain.
- The receptors are like a lock and the chemicals are like a key – only certain chemicals fit into each type of receptor.
- As long as there are enough chemical messengers, the message will continue.
- If there are not enough, then the spinal cord will not send the danger message along.
In the Brain
When the message reaches the brain, it is send to many different areas. All these areas of the brain (and others) work together to process the message. If the brain decides a warning is needed, then pain is experienced!
- Sensory cortex: a representation of all the parts of the body to process info about sense of touch and location in body- where is this message coming from?
- Premotor/motor cortex: a representation of all the parts of the body to plan and execute movement – do I need to hold very still or move quickly to get away from danger?
- Cingulate cortex: attention gets pulled to focus on warning signal– why we are easily distracted in pain, have hard time concentrating on other things
- Prefrontal cortex: problem solving – lots of thoughts about the warning signal or pain – why is this happening? What should I do to solve this?
- Hypothalamus/thalamus: stress response turns on when there is a threat – danger signal processed as a potential threat! Part of protective system
- Amygdala: emotional centre of the brain, pain supposed to be unpleasant, useful to have emotions like fear, worry in short term
- Hippocampus: memory – remember last time felt the pain, what was involved. may walk past place where experienced lots of pain before or site of trauma and pain increases
In fact- many of the areas of the brain work together to produce the experience of pain. We can think of the brain like an orchestra playing a song. Everyone will play a little differently, even though the instruments are the same. Over time, our brains can keep playing the same song – plays it automatically, plays by memory, harder to play any other song
The Pain Experience
- We now know that the pain experience is not this simple.
- Other activities such as inflammation (the body’s normal response to injuries or infections) and neuropathy (nerve damage) also send alarm signals to the brain.
- Pain does not happen just because the brain receives “danger” signals.
- Danger signals are one of many signals from the body to the brain.
- Before the pain alarm turns on, the brain must put together a reasonable story from all the information it receives.
- The brain then decides what needs to be done next to protect you.
- The brain will decide what the signals mean: the context and meaning are important!
- Now suppose you step on glass, but this time, you are on a stage to receive a very important award. The piece of glass may cause little or no pain. This is not because danger signals are not travelling from your foot to your brain. It is because feeling very excited can stimulate nerve fibers and feel good chemicals that close the nerve gate. Closing the nerve gate slows down danger signals to the brain. Fewer alarm signals means the brain is less aware of dangers and less likely to protect you with pain. After your feeling of excitement comes down, you may start noticing a pain in your foot.
- Metaphor: brain is your body’s CEO who looks at a whole situation before protecting by pain and sending signals to close or open the gates.
In the body:
- Stimuli that might be dangerous are detected by nociceptors
- Nociceptors pass the signal on to the spinal cord and up to the brain
- The signal is interpreted by the brain
- Not every signal that reaches the brain is interpreted the same way. The brain gets a lot of signals and puts them altogether to determine what you will feel. This is also why not everyone has the same pain experience- even if they have the same painful event.
The Experience of Pain
Pain is more than the state of the tissues. You feel pain when the brain decides that there is a threat to the body.
- There is a tendency to think more pain means more damage and less pain means less damage.
- Animal and human studies show that tissue damage does not predict pain.
- Major injuries send stronger danger signals but danger signals are not pain.
- Pain happens when the brain interprets these signals and decides that there is a threat to the body.
The danger is always being compared to other situations the person is facing.
- It is possible to feel pain when there is no tissue damage.
- Or to feel no pain when there is tissue damage.
- Pain is more about what the brain thinks is dangerous than it is about tissue damage.
- Knowing the context or meaning of your pain is important to understand why you have pain.
- Context is important to understand why we have pain.
- Pain is a message the brain sends to the body when it decides you are in danger and need to take action.
- The brain quickly and unconsciously decides how dangerous a situation is.
- The danger is always being compared to other situations the person is facing.
Acute Vs. Chronic Pain
The human body as a house and chronic pain as a smoke alarm that keeps going off. When the alarm turns on, your natural reaction is to look for a fire. If you search the house and do not find a fire time after time, you need to check the alarm itself. Maybe the settings are too sensitive and it picks up other activities in the house (e.g. footsteps). Like a smoke alarm that goes off with no fire, chronic pain is more about having a highly sensitive nervous system producing pain than tissue damage.
What is happening in the body?
- Neuroplasticity is the ability of the brain to change over time.
- The pattern of connections between brain areas can become like a well worn path.
- When you use the same parts of your brain together, and they send messages back and forth the same way over and over, it is like creating a faster path.
- Neuroplasticity happens throughout your whole life, not just as children/teens.
- Anytime you learn or experience, or remember anything, you are changing the connections in your brain.
- Sometimes this is referred to as “what fires together, wires together” – the parts of the brain working together communicate more quickly over time.
- Central sensitization means that the brain and spinal cord have become more sensitive to various types of stimulation.
- This persistent state of reactivity lowers the threshold for whatever causes pain.
- Central sensitization has two distinct characteristics:
- Hyperalgesia – things that hurt start to hurt more
- Allodynia – things that didn’t hurt now hurt
Brain connections are like paths in snow...
- Metaphor: chronic pain is a smoke alarm in your body with sensitive settings.
In the body:
- Chronic pain is less about tissue damage and more about having a sensitized nervous system.
- Different activities easily turn on the pain alarm system.
- Chronic pain not a sign that the body is in danger.
Some ways the brain changes pain
The Body Map
- The virtual body map or homunculus is an area of the brain where all of the parts of the body are represented.
- This body map helps explain why people can have pain even when there is no damage to that body part.
- There is even a condition called “phantom limb pain” in which people who have had an amputation still feel pain in the missing limb. The pain is actually being processed in the brain’s virtual body map. This can happen without having an amputation – it can be part of central sensitization.
- Over time, the areas representing different body parts on the virtual map can “smudge” together, making it feel like the pain is spreading to other areas of the body, even when there is no new tissue damage or harm.
Access for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction
- People who have been in car collisions often report their pain increases when they visit the scene of the collision.
- The memory part of the brain can activate the “pain song” and send danger messages to the other parts of the brain.
Thoughts and Emotions
- Thoughts that increase our perception of threat can activate the “pain song.”
- For example, every time we think, “My back is wrecked,” or, “It’s bone on bone in there,” or, “my body is falling apart,” this strengthens the connection between the thought, movement, and sensory areas of the brain.
- It is easy for your brain to follow that well-worn pathway.
If you start thinking a new thought, like, “this aching is uncomfortable but it isn’t dangerous,” then over time that thought becomes connected to the sensation instead, and may become a more automatic thought pathway. This can decrease the pain experience.
- “Neuroplasticity got you into this mess, and neuroplasticity can get you out again!”
- Pain can last long after tissues such as muscle, bone, and nerves heal
- The nervous system changes over time in a process called “neuroplasticity”
- The areas of the brain that process danger signals and protect us with pain get more strongly connected and are more easily activated
- New pain or changes in pain can sometimes be explained by central sensitization
Pain is personal- everyone experiences it differently.
What is happening in the body?
It may be surprising, but our thoughts, feelings, and actions can actually change our body chemistry as well as how our brains communicate. Since pain is an output of the nervous system, many of these inputs below can be part of the information the brain considers when deciding whether or not protection by pain is needed. Below are some of the factors that influence the sensitivity of the nervous system.
Our Pain U Online
- We have created modules that will provide you more information on many of these factors and will provide strategies to help you cope!
- Pain, Cognition and Sleep
- Pain Flares, Flare-up factors, Warning signs
- Physical Activity
- Pain and Communication
- Stress management
In chronic pain, the brain creates unnecessary danger messages due to changes in the nervous system.
- Identifying factors that affect our own pain can be helpful to understand what makes pain worse or better.
- Thoughts, feelings, beliefs, stressors, and actions related to pain can be danger signals that amplify pain or safety signals that decrease pain.
Managing Chronic Pain
How do you manage chronic pain?
- The first step is to understand what is happening in your body.
- Knowing what is going on can make you feel less afraid and less pain.
- This makes sense because your brain protects you from what it thinks is dangerous.
- Once your brain understands you are not in danger the pain experience decreases.
But what if pain persists?
- In chronic pain, the nervous system is changed and becomes overexcited by things that usually cause pain and things that do not usually cause pain.
- There are many ways to make your nervous system less excited.
- Some require help from medical professionals and some do not.
If you have been living with pain for a long time, it will take time to turn down your alarm’s sensitivity. Be patient. Your pain can improve little by little over time.
Strategies to manage chronic pain include:
Self-management and medical treatment are both important parts of your pain management plan. Ongoing self-management of your pain and health care allows you to be the one in charge of your health, and is important regardless of your diagnosis or health condition.
Self-management programs help people to:
- Learn new ways to solve pain related issues
- Change habits (improve sleep, activity, function)
- Learn how to find and use community resources
- Learn to communicate and advocate with your health care team
Learn more about pain
Learning about pain and pain management tends to help people feel more confident and less fearful, which are powerful safety messages.
Learn about Pain
Finding healthy, effective ways to cope with stress begins with knowing what tends to cause you stress, and what stress feels like for you. You can think about stress management like turning down the heat on a pot of water before it boils over.
- Identify patterns of stressors: people, places, body sensations, weather, mood, activities, internal or external
- Identify warning signs: body sensations, emotions, and behaviours that are clues to stress ramping up
Coping with stress can include the following strategies:
- Find outlets for frustration
- Deep breathing, Enjoyable exercise, Meditation, Creativity
- Regular relaxation
- Guided relaxation techniques, Experience nature, use heat or cold, self-massage, visualization
- Gain social support
- Talk to caring people, Give support to others
- Create predictability and routine where possible
- Budgeting, Schedules
- Figure out where it is helpful for you to have control
- Create realistic goals, Be aware of your feelings
Physical Activity and Exercise
Physical activity is:
- Any body movement, using muscles, requiring increase in use of energy
- A type of physical activity
- Planned and structured body movement to improve physical fitness
In persistent pain, physical activity and exercise have an important role in re-training the brain. Physical activity can improve sleep, mood, and energy, and can decrease pain from deconditioning. Gradually getting used to movement in ways that feel safe and calm helps to decrease the brain’s assessment of danger. Avoidance of painful activities reinforces the brain’s assessment of danger.
Physical activity may require pacing or activity adaptation to help you keep doing what you need and want to do.
- Balance activity and rest
- Over-resting can lead to pain from deconditioning
- Over-doing can lead to pain flare-ups
- Adapting activity
- Find creative new ways to keep doing what you need to do and want to do
- Prioritize, take breaks, delegate, use tools and adaptive assistive devices
Thoughts and Emotions
- Coping self-talk, e.g., “This hurts but doesn’t harm me.” “This is uncomfortable now but I know it will fade.” “I can feel pain and still feel calm.”
- Talk with a friend, loved one
- Spend time with a pet
- Write in a journal
Formal therapeutic strategies for coping with difficult feelings or thoughts:
- Cognitive behavioural therapy (CBT)
- Acceptance and Commitment Therapy (ACT)
- Mindfulness-based stress reduction (MBSR)
- Trauma Therapy
- 50% to 80% of people with persistent pain have trouble with their sleep.
- The body systems that make us sleep are guided by cues such as light and darkness, activity level, and routines.
- Benefits of sleeping well include improved memory and concentration, improved immune system, lower stress, more energy, less pain intensity, and faster healing.
TIPS for restful sleep:
- No screen time 1 hour before bed
- Limit caffeine in the afternoon or evening
- Exercise regularly
- Have a bedtime routine to wind down (bath, comfy clothes)
- Limit water or alcohol before bed
- Limit day time napping
- No kids or animals in bed
- Go to bed around the same time each day
- People with pain are more likely to smoke than the general population
- People who smoke rate their pain higher than people who don’t
- Nicotine may decrease pain in the moment that you are smoking, but causes long term increases in pain
- Things you can check off a to-do list
- Activities involving concrete actions
Why bother to set goals?
- Helps us know if we’re living according to our values
- Helps to stay organized
- Helps to stay motivated
Often, we set goals that are too big or hard to achieve. Setting small, meaningful, SMART goals can help you to see more success.
Plan for Flare-ups
- Flare-ups are a normal part of having persistent pain, and are an increased intensity of pain experience in response to changes in environment, activity, overall health, or stress. Flare-ups are time-limited and have an end.
- Create a flare-up toolkit to help you through the pain flare-up.
When using medicines to manage pain, the 5 “S” Medication Principles should be used.
- Striking a balance between benefits and risks: The benefits (pain relief) should always be weighed against the risks (side effects) of using medicines.
- Significant pain relief: Medicine is helpful if it reduces pain by 30% or more.
- Safe use of opioid medications: Pharmacists can give you tips on safe opioid use.
- Self-Medications and prescription medications: Have a current list of the medicines you are taking and understand who, what, when, how, and why you are taking them.
- Safe storage and disposal of medications. Medicines should be stored in a safe place (locked cabinet) away from kids and pets. They should be kept away from heat, cold, and moisture. Always leave medicines in original labelled containers. Do not mix medicines in same container.
Tips to minimize harm from medication use:
- Avoid long-term (more than 1 month) daily use of medicines like:
- nonsteroidal anti-inflammatory drugs
- Talk to your health care provider about "de-prescribing” (reducing or stopping medicines that are no longer helping).
- Take medicines according to their recommended dose. Increasing doses of some medicines does not always have more benefits for pain.
Surgical Interventions (require medical personnel)
Surgical interventions are invasive procedures that reduce chronic pain in some people with some conditions. Some examples are:
- Epidural steroids: Injecting steroids into the spine to reduce inflammation around the nerves in the spine.
- Nerve Blocks: Injecting medicines to “numb” or freeze the nerves.
- Radio frequency ablations: Using radio waves to stop some nerves from sending danger signals to the brain.
- Neuromodulation stimulation: Inserting tubes into the body to deliver electricity to the nerves along the spine to block pain signals from the brain.
There is no guarantee that these procedures will work. These procedures are “successful” if a 50% or more decrease in pain is achieved.
- Education is critical for you to improve function and live better with your pain.
- A key is to understand why your pain may not always inform you about tissue damage.
- Self-management strategies are a necessary part of managing chronic pain.
- Be patient and persistent. You can use smart activities to gradually increase your activities and involvement in life.
Resources for Learning about Chronic Pain
- TAPMI Pain Management Manual
- Why Things Hurt by Lorimer Moseley
- Changing your pain pathways by Bonnie Cai-Duarte, Cara Kircher, Bronwen Moore, Sarah Sheffe 2018 Toronto
- Explain Pain by David Butler and Lorimer Moseley 2003 Noigroup Publications: Australia
- A Patient Book about the Neuroscience of Pain Adriann Louw 2013 International Spine and Pain Institute (USA)
Explaining Chronic Pain to Persons Living with Chronic Pain
- Butler, D. S., and Moseley, G. L. (2003). Explain Pain. Noigroup Publications: Australia.
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- Facet Joint Injection https://www.spine-health.com/video/facet-joint-injections-procedure-video
- Anti-Inflammatory Medications for back pain https://www.spine-health.com/video/anti-inflammatory-medications-back-pain-relief-video
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