Living with Chronic PainAlec Rickard - Lecturer in Physiotherapy, School of Health Professions, University of Plymouth This article is based on a presentation delivered at the LUPUS UK Annual Convention, Sunday 13th May in Plymouth. The author does not intend to attempt to provide answers for everybody, nor wish to criticise/undermine anyone's current pain management strategies. All pain is real (to the person experiencing it) and unpleasant (usually - we will ignore sadomasochists!). However, knowing that does not really help you deal with it; cope with it; live with it - day in, day out, 24/7. In order to begin the journey towards trying to take control of your pain, it is important to, first, challenge a couple of common misconceptions. Many people consider pain to be a sign of damage. Usually it is and that is why having a pain system is actually very helpful, particularly as pain may prevent further - possibly greater - damage. We usually react to pain (change our behaviour - do something about it), which may mean stopping doing what we are currently doing or limping in the case of a twisted ankle. However, is pain always a sign of damage? Consider a headache, emotional pain or hunger pains, something most of us have experienced several times. Likewise, does damage to the body always cause pain? Sports injuries feature prominently here, with many reported cases of various athletes injuring themselves quite seriously, without seemingly being aware of it and continuing their activity. One of the most famous examples was of Bert Trautmann, goalkeeper for Manchester City in the 1956 FA Cup final. After a collision with an opposing striker, he played the remaining 15 minutes unknowingly with a fractured vertebra in his neck. Additionally, pain is not always in proportion to the amount of damage. For example, think how painful a paper cut can be for what appears to be a tiny amount of damage. This last example is more easily explained, compared to the previous examples, in terms of how sensitive different tissues, such as your skin, are: a deeper cut is sometimes less painful, at least initially. However, you may have noticed the pain that you experience because of, for example, your joints or muscles, varies on different days. Sometimes there does not appear to be an obvious reason for it, plus even the strongest pain killers may not even touch the pain, let alone kill it. For centuries scientists, doctors and other health professionals have attempted to explain how - and why, hence philosophers were one of the earliest to try - we feel pain. Then, in 1965, there was a breakthrough when an anatomist and a psychologist came together to propose the "Gate Control Theory of Pain" (see figure 1). This model appeared to answer some of the mysteries of pain and was the first to really acknowledge that pain is not a simple one-way message from the site of injury to the brain and suggested a "gating" mechanism, whereby the gate is either opened, and more pain is felt, or closed and less pain is felt. It emphasised the importance of the brain in interpreting the information received from our tissues and then modulating, or controlling, the final sensation we experience as pain. In some situations, the pain can almost be blocked completely, as in sports injuries, or battlefield stories of soldiers rescuing colleagues despite serious injury, such as amputation, to themselves. Additionally, sensations from other parts of the body may also open or close the "gate", such as the levels of pre-existing pain or tension in muscles.  Figure 1. Diagrammatic example of Melzack and Wall's Gate Control Theory of Pain. Some people have therefore suggested that certain nerves could be cut, to stop the transmission of pain. However, it is not as simple as that. Firstly, nerve fibres are bundled together, so that fibres that carry pain messages are also next to fibres that carry other sensation, such as touch, as well as messages going from the brain to the muscles to enable movement. Therefore cutting a nerve will also affect these other functions. Secondly there are many different nerve pathways that messages may travel along so, just as you may have a traffic jam on a motorway and can then use various A or B roads to get around it, our bodies have interconnecting nerves and do not rely on just one route for messages to travel along. This is commonly seen in phantom limb pain after an amputation - physically removing a part of the body (including the nerves) does not mean that pain is still not felt where it used to be. Okay, if cutting the nerves does not work, how about stopping the brain feeling the pain, by removing or destroying the part of it responsible for pain? Aside from the fact that brain surgery is inherently risky, it is also difficult to identify a single "pain centre" within it (see figure 2). Additionally, we need to feel some pain in order to protect ourselves and survive. If we were to not feel any pain at all, how would we know if the iron was burning us, or a nail had worked its way through our shoe and we continued to walk on it? In the burning example, pain is often felt as a warning before any significant damage occurs, as long as we react to it quickly enough, such as pulling our hand away.  Figure 2. The different parts of the brain and their functions associated with pain. However, the gate control theory of pain is not all doom and gloom. The good news is that it demonstrates that the amount of pain felt can be modified and even controlled to different extents. There are various things that you can do to close the "gates", such as:
This last one is usually the one people most struggle with. If your pain levels vary day-to-day, or you have had a period pain that is then easing, it could be very tempting to try and take advantage of the good days, perhaps because you need to catch up on jobs or chores, or you just want to get out and do something. However, this can easily lead to over-doing it, following which a flare-up of pain may occur, leading to then having to take a rest period. This can become a vicious cycle (see figure 3).  Figure 3. Vicious cycle of pain and activity. Instead of this cycle, a paced approach - just as a marathon runner would do - is needed for exercise or, indeed, any physical activity, which may include the gardening or walking to the shops etc. Pacing basically means not pushing into or through the pain barrier (leave the "no pain, no gain" motto for the Marines to suffer!). The solid line on the graph in figure 4 shows an unpaced approach of good and bad days, with activity levels varying according to the pain. What you should be aiming for is the dotted line, whereby activity levels are gradually increased. Now, this is not easy, but it can allow the activity levels to be less dependent on having a good day. By not over-doing it, there is less risk of flaring up the pain and, therefore, it is possible to do some activity on more days. This way your tolerance or fitness for that activity improves. There are three P's to pacing: prioritise, plan and practice. Prioritising is important as it is not possible to pace everything at once - you may have some things that have to be done at, or within, a certain time, such as taking children to school. So pick something that is realistic and achievable (some people have heard of SMART goal-setting: Specific, Measurable, Achievable, Realistic/Relevant, Time-bound), such as walking to the local shop. Planning is also important as doing things in a paced way can take longer and may require things to be done differently or assistance to be sought. If for example, the shop is 10 minutes walk away, but your pain level is usually increased before you get there, then you need to work out what is your current baseline. So instead of pushing through to the full 10 minutes, what if you were to time yourself and stop at 5 minutes and then have a short rest, such as sitting on a bench or wall (this is where the planning can help)? Then walk to the shop, do your shopping and perhaps have another short rest, before walking for 5 minutes with another rest and then finally home. By doing it this way, you are stopping the pain from accumulating too much and it can then settle a bit during the rest, before you walk again. After doing this daily for a week (the third P - practice, as it can be tempting to do more than the 5 minutes if you are feeling good on a particular day), if there are no problems, then you could gradually increase the time you walk for between stops, such as 6 minutes, then 7 the following week etc. This principle does not just apply to walking, but any activity or exercise. Some people prefer to be more specific about working out their baseline, by walking daily for several days and then recording at what time their pain started increasing. The baseline is then taken as the average of these. Whatever you prefer, it can be useful to bear in mind that most of us tend to overestimate our abilities, so if you think you can do something comfortably for 10 minutes, it may be useful to be a bit cautious initially and aim lower. That way you will avoid over-doing things and can soon start to gradually increase.  Figure 4. Solid line = unpaced activity; dotted line = paced activity. The techniques described here for pacing are skills that often need learning and practicing - they may not come naturally to some people, particularly those that feel they have to finish something that they have started, so patience is needed. Pacing does not prevent you having flare-ups in pain that may occur as part of the natural cycle of your particular condition, rather it tries to minimise the risk of flare-up from your own behaviour. If you tend to suffer specific flare-up episodes in your condition, then gradually pacing-up your activity levels and fitness between these may help you deal with them better and also put you in a better position to get back on track once it has settled. You may probably have to reset your baseline or start lower again to build back up, but progression may also be quicker each time. Further, specific advice may be available from a local physiotherapist, especially those that deal with rheumatological conditions or specialise in pain management. The following sources offer further general advice:
Acknowledgements: Thanks go to Sally Bryan, physiotherapist at Devon PCT, for her help with the original presentation given at the Annual Convention. |
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