I have worked with patients with chronic pain for most of my career now. Lately I have started to teach about it in a module for students from physiotherapy, nursing, occupational therapy, midwifery, etc. I was utterly shocked to hear a future health professional asking me how you could tell if they were faking it! Faking what?, I said. He very innocently said: “the pain”. Clearly, there was a lack of knowledge and understanding.
Chronic pain, just like mental health problems, still is a stigmatised condition by the general society. Both are “hidden” from the human eye, meaning that the suffering and the limitations can go unnoticed (or may be not even been believed). However, nobody questions anything when someone has developed a cold sore after they have had a stressful period of time; or that when a student is stressed before exams and they need to go to the toilet more often that usual. Those are things that can be seen or measured, but proves that there is a link between psychological factors and physical symptoms.
Let’s start from the beginning
Pain is defined as an unpleasant and subjective sensation. This means that everybody feels pain differently and that it cannot be measured by others, except from the sufferer him/herself.
Broadly speaking, there are 2 types of pain: acute or chronic. They are both pain but they are very different. Acute pain always comes after an injury or a physical trauma. It is completely normal and, in fact, acute pain is one of our body’s natural defence mechanisms. It serves a purpose and it gets better over time as the injury heals. However, chronic pain is different as it does not serve any purpose and it may or may not be related to an injury.
Chronic pain is defined as pain that extends beyond the expected period of healing, usually considered between 3-12 months (depending on where you are reading). The reason why an acute pain progresses to chronic is still fully unknown, but we do know that there are some biological, psychological and social factors that “help” to make this transition. These factors can vary from a genetic predisposition and previous traumas (physical or psychological) to general physical deconditioning, fear of movement, etc.
There is a lot of published research that proves that those with a history of mental health problems are more likely to develop chronic pain in the future; and also, that the existence of chronic pain is associated with mental health problems. It’s a vicious cycle: one leads to the other and vice-versa. I would like to note here, that not all patients with chronic pain develop mental health problems nor of the same severity; and not all patients with mental health issues will end up with chronic pain.
But the link between mental health and chronic pain doesn’t end here. It has been demonstrated that the Nervous System in those with chronic pain is hypersensitive and hyper-reactive. In plain English, it means that people with chronic pain feel otherwise normal sensations more and their bodies have a stronger reaction to them.
The battle: brain VS body
However, the process of chronic pain gets even more complicated as substances that are naturally in our body and brain, also get involved. The amount of these natural substances changes, affecting some brain areas (called the limbic system) that control motivation, short-term memory, fear and mood.
When we combine an active and healthy lifestyle (sleep, diet, stress reduction, etc) our limbic system starts to improve. This is why a treatment for patients with mental health and/or chronic pain problems needs to have a holistic approach with, at least some involvement of a doctor, a psychologist and a physiotherapist.
Physiotherapists can help to develop an active lifestyle providing a structured exercise program adapted to the individual needs. These exercises will change our strength and fitness level in time and will, ultimately, help to improve our fatigue levels. Exercises can vary depending on the individual tastes and realistic possibilities. Going for a walk, swimming or going to the gym are all great ways of exercising, but not the only ones. As we exercise regularly and our physical condition improves, so will our limbic system.
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