7 Ways to Reduce Chronic Pain
Tips to decrease your pain and get you back to the things you enjoy!
Recap: Key points about chronic pain
To gain a further understanding about chronic pain and its causes, please read my last post defining chronic pain.
– Chronic pain affects more than 100 million people. This is more than heart disease, cancer, and diabetes combined.¹
– Pain does not equal tissue damage. Pain is an output our brain creates based on a perceived threat.
– With chronic pain, there is increased baseline nerve sensitivity. With this increased sensitivity, smaller motions that shouldn’t be painful begin to cause pain.
– Chronic pain tends to be diffuse vs specific. The somatosensory cortex begins to undergo changes which causes difficulty in the brain being able to interpret sensation.²
– Chronic pain tends to spread. Our nerves are very interconnected and when the alarm in the low back begins to go off, it also can affect the nerves in our mid back or hips.
#1: Education
So here is the good news! By reading this and my last post then you have already begun to decrease your nerve sensitivity. Studies show that improved knowledge of pain neuroscience can enhance movement, improve coping skills, and potentially lower disability³⁴. In fact, one study looking at low back pain and physical therapy found that patients had less pain when they were taught how their pain worked⁵.
Understanding your pain is a key factor for improving it. If you can begin to notice which activities and stressors make your pain worse, then you can have more control over your pain.
Besides reading the blog posts I have also provided two book recommendations to improve your pain neuroscience knowledge.
Chronic Pain Book 1: Why Do I Hurt — Adriaan Louw
Adriaan Louw is one of the leading pain neuroscience researchers right now. His book explains pain via pictures and stories and makes a complex topic much easier to understand.
Chronic Pain Book 2: Explain Pain — David Butler and Lorimer Mosely
I personally have not read this one but have had other physical therapists recommend it to me. From what I have gathered, this book talks a little more about the details and physiological events that occur with chronic pain. If you are a person who wants to know exactly what is going on physiologically, this may be your better option. However, this book is a little pricier and you must have some medical terminology knowledge to fully follow along.
#2: Aerobic Exercise
To continue decreasing nerve sensitivity, aerobic exercise should be done ideally 10–20 minutes 3–5x/week. The main target to strive for is to have your heart rate greater than 100 bpm.
For aerobic exercise, it is important not to go too intense in the beginning. The goal should be some soreness while exercising but you want to avoid any intense pain. Start small and increase slowly. The first day should be no longer than 10 minutes. See how you feel after that, then adjust as needed. Remember, it took the pain months to get to this point so it will take some time to get your nerve sensitivity levels back to baseline. Any exercise is a victory even if it is only five minutes.
#3: Pacing
Pacing is the idea of doing short spurts of an activity and then resting. What I commonly see in the clinic is someone with chronic pain walks in and is feeling a lot worse than last visit. When I ask what is going on they state they were feeling really good following treatment and decided they were going to do yard work for 1–2 hours. This flared their back pain up and now they are in worse pain than before.
Pacing is the perfect way to prevent this from happening. To pace, you need to determine how much yard work is realistic for you before your pain begins. Let’s say 20 minutes is what you decide. You should then start small and only do yard work for 15 minutes followed by 60 minutes of rest. If you feel okay after your 60 minute rest, you can go and do 15 more minutes of yard work.
The tortoise and the hare
To most people, this sounds like it is going to take forever to do, and truthfully it will take 5 hours to do 1 hour of yard work. However, you are missing the key point: 5 hours with slight soreness afterwards is far better than 1 hour of work with 12 hours of pain limiting you from doing anything the rest of the day but laying on the couch.
The goal is that each week you can slightly increase how much work you are doing without experiencing signifiant pain. It is a marathon not a sprint. If you had pain with that activity for months and years it will take a couple of months to be able to do the entire task without pacing.
Key points for pacing
1. The goal is to prove to the body that this activity is safe and decrease nerve sensitivity. If you go too hard and too fast, this will only increase the sensitivity making it more painful in the future.
2. Your pacing goal should be based on your current ability, not your past ability. Too many people make their goal based off what they were able to do months ago. Make the goal based on what you can tolerate now.
3. As a particular task becomes easy, you can increase the work time SLOWLY.
4. Never change more than one variable at a time with pacing. You can do yard work for more minutes before resting or perform slightly harder yard work (ex: raking vs pulling weeds) but both should not be increased on the same day.
#4: Graded Motor Imagery
Introduction
In the recap, I mentioned that the somatosensory cortex starts to undergo changes with chronic pain. This almost blurs your map of your body in the brain causing the pain to become diffuse and generalized vs in a specific spot. Graded motor imagery consists of three different techniques to help restore your body map and reverse the changes caused by chronic pain. Below is a video that explains this in an easy to understand way.
Technique 1: Left:Right Discrimination
This focuses on improving the brain’s ability to determine what is a left foot/hand vs a right foot/hand. It has been shown that people with chronic pain take significantly longer to determine whether a picture is a left or right hand/foot⁸.
I recommend using the app Orientate — Pain Management. It is free on iOS and Android and will track your previous times performing the test so you can track your progress. It is best to perform the task on the body part that is bothering you.
Technique 2: Motor Imagery
Motor imagery is the process of imagining a particular movement. The idea is that by visualizing yourself in a position that you would normally be fearful of, the nerves sensitivity begins to decrease.
When performing motor imagery, it is important to follow the rules below to avoid increasing pain:
– Start by imagining pain-free positions ➜ progress to positions that are usually painful
– Begin with static images where you are not moving (ex: sitting in a chair) ➜ progress to moving visualization (ex: walking)
– The goal is to make it seem as real as possible, so add specific details such as temperature, smell, the texture of objects, etc. The more details added the better.
Example of motor imagery
If I was very fearful of climbing a ladder because it caused me pain, I might perform the following visualizations over the course of a month. I would spend 5 min each day visualizing the following:
Week 1: Me standing still outside. I might even progress to me standing next to a ladder.
Week 2: Me performing a task somewhat similar but not as painful as going up the ladder such as going up a set of stairs. I could also visualize me putting my foot on the first rung of the ladder and then setting it back on the ground.
Week 3: Next I would visualize me standing still on the first rung of the ladder. As the week progresses, I could visualize myself on a higher rung of the ladder each day.
Week 4: Finally, I would begin to visualize myself going up the ladder. In the beginning I would just step up on the first 1–2 rungs and by the end I would visualize myself going all the way up. I could even continue progressing and visualize going up the ladder while holding an object in my hand such as a paint brush.
Technique 3: Mirror Therapy
The last technique in graded motor imagery is using mirror therapy. If one limb is in pain, we can use a mirror to make it look like that limb is moving when it is actually the pain-free limb moving. I remember first hearing about this and thinking there is no way that this could be beneficial, but I have had success with patients and studies have shown that it can be beneficial after a stroke, with phantom limb pain, and for chronic pain⁶.
It is hard to explain this with writing, so I have included the video below to provide as an example. The key is that your left:right discrimination task must be restored to normal levels first. If not, there is the risk of actually increasing pain vs decreasing pain due to the brain’s poor body map. It is recommended to perform 10 min/day, every day, for one month.
#5: Medication
Speak with your physician as there are medications that can help improve nerve sensitivity. Some medications which have been found to possibly be beneficial for central sensitivity are anti-convulsants or anti-depressants. There are also medications such as muscle relaxants that may be useful.
#6: Meditation
For many people, stress can be one of the key things that increases their pain. Stress causes our sympathetic nervous system to be on high-alert. This is the fight or flight system in our body and commonly leads to increases in pain. We also have a system called the parasympathetic nervous system — this is our rest and digest system. The sympathetic nervous system can be good at times, such as when you are in danger and need adrenaline to focus and move quickly. However, your parasympathetic system should be the primary system during your everyday state.
4 second inhale + 8 second exhale = more relaxed state
One of the easiest ways to activate the parasympathetic system is to breathe in for 4 seconds followed by exhaling for 8 seconds. This has been shown to stimulate the vagus nerve which is one of the key nerves of the parasympathetic system⁷. Try doing this for 10 breaths when you are stressed to put you in a less stressed state.
Progressive Muscle Relaxation
Another common meditation is progressive muscle relaxation. If you notice that you have a lot of tension in your muscles, I would recommend giving this a try and seeing how it affects your pain. There are many different ways to do this, but most go through each body part and have you contract the muscle for 3–5 seconds then completely relax it. Below is a guided video and you can find many more online.
#7: Physical Therapy / Corrective Exercises
With chronic pain comes compensation. People find particular ways to do things to avoid pain and avoid activities that cause pain. For example, many people with chronic low back pain tend to lean a certain way each time when they sit. This can lead to particular muscles getting tight and others getting weak. Physical therapy or other rehab professionals may be beneficial to help you get a better grasp on some specific exercises to address these deficits to help reduce pain.
Citations
1. David B. Reuben, Anika A. H. Alvanzo, Takamaru Ashikaga, G. Anne Bogat, Christopher M. Callahan, Victoria Ruffing, David C. Steffens. National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Annals of Internal Medicine, 2015
2. Kuner, Rohini, and Herta Flor. “Structural Plasticity and Reorganisation in Chronic Pain.” Nature Reviews Neuroscience, vol. 18, no. 1, 2016, pp. 20–30., doi:10.1038/nrn.2016.162.
3. Adriaan Louw, Kory Zimney, Emilio J. Puentedura & Ina Diener (2016) The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature, Physiotherapy Theory and Practice,32:5, 332–355, DOI: 10.1080/09593985.2016.1194646
4. Watson, James A., et al. “Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis.” The Journal of Pain, vol. 20, no. 10, 2019, doi:10.1016/j.jpain.2019.02.011.
5. Wood, Lianne, and Paul A. Hendrick. “A Systematic Review and Meta-Analysis of Pain Neuroscience Education for Chronic Low Back Pain: Short-and Long-Term Outcomes of Pain and Disability.” European Journal of Pain, vol. 23, no. 2, 2018, pp. 234–249., doi:10.1002/ejp.1314.
6. Daniëlle Ezendam, Raoul M. Bongers & Michiel J. A. Jannink (2009) Systematic review of the effectiveness of mirror therapy in upper extremity function, Disability and Rehabilitation, 31:26, 2135–2149, DOI: 10.3109/09638280902887768
7. De Couck M, Caers R, Musch L, Fliegauf J, Giangreco A, Gidron Y. How breathing can help you make better decisions: Two studies on the effects of breathing patterns on heart rate variability and decision-making in business cases. Int J Psychophysiol. 2019 May;139:1–9. doi: 10.1016/j.ijpsycho.2019.02.011. Epub 2019 Mar 1. PMID: 30826382.
8. Breckenridge JD, Ginn KA, Wallwork SB, McAuley JH. Do People With Chronic Musculoskeletal Pain Have Impaired Motor Imagery? A Meta-analytical Systematic Review of the Left/Right Judgment Task. J Pain. 2019 Feb;20(2):119–132. doi: 10.1016/j.jpain.2018.07.004. Epub 2018 Aug 9. PMID: 30098404.
