Chronic pain is not like acute pain in that the level of pain is not directly related to the extent of injury. For this reason, physiotherapists and other chronic pain specialists use a different approach with sufferers of chronic pain which centres around encouraging them to take regular gentle movement or exercise and not push themselves beyond their limits.
The key to chronic pain management, according to Sheila Horan and Ruth McCollum, senior physiotherapists at the Pain Clinic at Tallaght University Hospital, is to understand and recognise your limits and work within these. "Back pain is the most common health problem and often people with back pain stop doing things and take to the bed. They hold their bodies stiffly, move very carefully, guarding their muscles and holding their breath," explains McCollum.
Instead, people with chronic pain should learn what kinds of movements they can do without triggering a flare-up in pain. “We start with patients telling us their story and in their story, we will pick up nuggets of information that will help us direct them to best manage their pain so that they can function better,” says Horan.
“We gently address the myths around chronic pain and explain how, for example, their back isn’t fragile and their bodies are quite robust. We guide them to do a manageable amount of movement or exercise so they can have the experience that it is safe to bend and move. Then, it’s about building on that,” adds McCollum.
Many people with chronic pain believe that they need a scan to diagnose their pain properly yet for most of these, a scan isn’t necessary. “A good clinical examination can determine whether you need a scan, based on your history, symptoms and examination findings,” says McCollum.
“Ninety per cent of back pain patients won’t benefit from a scan as it won’t influence their treatment,”she adds. About 1 per cent of patients who have severe and debilitating pain, will warrant a scan to identify if they have a broken bone or if there is an underlying disease such as an infection, an inflammatory condition or cancer. And the other 9 per cent will need a scan to identify if a disc affecting the nerve is causing loss of power and sensation in their limb.
McCollum and Horan work hard every day to dispel common myths of chronic pain and encourage patients to learn how to manage their pain better. Their mantra is, unlike with acute pain (sudden pain after a specific incident), that chronic pain is not a good indicator of harm or injury.
Misleading beliefs about chronic pain include that you will cause damage if it hurts during activity, that bending and lifting will make low back pain worse, that bed rest – and/or strong pain killers (opioids) are the best treatments for chronic pain.
To best manage chronic pain, a more holistic approach is required and lifestyle factors such as mood, stress, sleep, home and work life must be taken into account. “For many people, we see their pain impacts on many areas of their life and they would benefit from learning coping skills to help manage this impact,” says Horan. “In work, for example it may mean an employer allowing individuals with chronic pain regular breaks from their desk jobs to allow them incorporate stretches into their day. These small changes can have a big impact.”
Both physiotherapists agree that the specific exercise or movement varies from person to person and the best thing is to do what you enjoy whether that’s gardening, walking or swimming. “We’re looking for functional movement and using breathing to hold your body in a softer way. The key is for each person to experience the benefits themselves,” says McCollum.
“People can underestimate the benefits of gentle, small regular exercises for chronic pain management. It’s about pacing yourself, managing your stress and not overdoing it,” adds Horan.
Managing chronic pain: two people's stories
Patricia Healy (24) has had chronic pain in her left arm – and more specifically in her wrist – since she was a teenager. "I tried for a long time not to allow it to affect me but sometimes, I didn't even want to get out of bed because I couldn't move my arm."
After several years of seeing specialists, Healy was referred to the pain clinic at Tallaght University Hospital. “One of the first things, the physiotherapist told me was to recognise my limits and not to push myself to those limits. Before that, I would have done myself harm by pulling open a heavy door or lifting a chair,” explains Healy.
She also learned to manage the psychological dimension of pain and “not to let it take over my whole body and mind”. Healy previously wore a sling on her arm “to protect it” but the physiotherapists advised her to abandon the sling and learn to use her arm within a certain range and recognise when to stop. “I also have learned to take a few minutes to breathe when I’m in pain.” Healy, who has just started her first job as a secondary school teacher, has check-ups with her physiotherapist every two months or so. “I always wanted the pain to be gone but now, I’m not negative about it. I have it. I deal with it and I live my life the way I want to.”
Paul is a 57-year-old plant fitter who has suffered from chronic pain in his back for over 20 years. More recently, he also suffers from neck and joint pain and was diagnosed with arthritis seven years ago. “I’ve seen orthopaedic surgeons but nothing can be done so I was referred for pain management 18 months ago,” he explains.
He says that only then did he realise he was doing “everything wrong” in terms of managing his pain. “I would push myself too far, get a flare-up, be out of work for weeks, let it settle down, go back to work and repeat the process.”
The biggest lesson he has learned from physiotherapy sessions is not to push himself too hard. “I’ve learned to push myself to the point of pain but not to torture myself, to find easier ways of doing things even if it takes an extra hour and respect the threat of pain.”
He says that he finds it difficult to do specific exercises but that he walks for 30-45 minutes four or five days a week. “I haven’t had a flare-up since I started. I still have pain but it’s not incapacitating. I missed far fewer days at work. I’m sleeping better and am more relaxed in myself because I’m not living in fear of pain.” He is no longer attending a physiotherapist on a regular basis.
The myths of chronic pain
A scan will give me a diagnosis – false
I am causing damage if it hurts during activity – false
Bending and lifting will make my low back pain worse – false
I should stay in bed and rest – false Strong pain killers (opioids) will help manage my pain – false
Surgery is my only chance of improvement – false
My pain and limited function mean there's nothing I can do – false
(Issued by the World Confederation for Physical Therapy, the global organisation behind World Physical Therapy Day on September 8th. See also wcpt.org)