Understanding pain

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					Pain Sensitisation
    A brief discussion of the psychological, hormonal and
  immune contributions to pain and what to do about them.
Pain is a remarkable alarm system designed to alert us to danger so that we can prevent further
damage and allow healing. However, this alarm system can stay turned on even when the danger is
gone (i.e. Injury is healed), or it can sound an alarm that is louder than necessary (pain out of
proportion to the problem). How does this happen? Well, nerves do not carry pain messages to
your brain, rather they transmit mere electrical signals. These signals can be made to trigger more
easily by chemically sensitising the nerve endings, magnifying (or reducing) the size of the signal
along its pathway. Once this signal has reached the brain its job is to interpret the signal by
unconsciously referencing the messages against past experiences and examining it with reference
to the current cognitive, emotional and physical environments. Your brain then has the final say on
how much pain you should feel and even whether it should bring it to your conscious awareness at
all. Can you see then that pain must be more than what is happening to the tissues where the
sensation of pain is felt? Read on!

Your immune system, your emotional state (i.e. Stress) and your endocrine (hormone) system all
powerfully influence the bodies chemistry and electrical activity in your brain and nerves which in
turn powerfully effects both the strength of the messages as they are transmitted through your
nerves as well as the interpretation of these messages by the brain.

The following pages help to guide you through some of the influences of pain outside the injury
itself. Addressing some of these factors in conjunction with advice of your health professional on
exercise, medication and other therapies with help you take control of your pain.

                                                      Information adapted from Explain Pain (Moseley, Butler 2003)   1
                                                                                Fear and stress
Contributor to pain? Stress and fear contributes to pain in many ways: 1. Many of the brain
areas which are used in creating conscious awareness of pain are also used in fear, stress and
depression . Therefore in these states the electrical activity in the brain areas associated with pain are
added to the electrical activity associated with the pain resulting in greater pain. 2. Various stresses in
our lives also change body chemistry and through the release of adrenaline and cortisol and activation
of the sympathetic nervous system. These are all capable of chemically sensitising the nervous system
to pain and increasing inflammation (nerve sensitising chemicals) in the tissues. These are all good
reasons to look after you psychological and social well being as well as your physical well being in the
treatment of pain. Make a list of some of the stressors in your life below. These may or may not relate
to your injury as shown in the example below. Consider how you might manage these and seek help if
      Fears /stressors
         Related to pain/injury                                        Not related to pain/injury
         Worried this pain will never go away                          Family problems
         Bad past experience of pain/injury                            Work stress/job security
         Afraid to bend my back                                        Finances

     Your fears/stressors:
         Related to pain/injury                                        Not related to pain/injury

                                                        Information adapted from Explain Pain (Moseley, Butler 2003)   2
                                                   Immune System and Pain
The immune system can contribute to pain in a number of ways such as increasing inflammation at the
painful site, sensitising nerves and mediating sensitising changes in the spinal chord and brain. There
are a number of things you can do that have been shown to improve immune system function. These
include feeling in control of your life and pain (see “Taking control” section), developing good coping
strategies, getting adequate sleep, having a healthy social life and support of family, friends and medical
staff, improving autonomy/sense of control of your life, laughing, having regular exercise and have a
strong belief system, a good diet and a positive outlook. Choose three of the things discussed and set a
goal for each one as a way of improving your immune health.

    Action                                                Goal
    Sleep more                                            Average at least 8 hours per night
    Socialise more with positive people                   Have weekly cup of tea with Jeff

    Action                                                Goal

                                                       Information adapted from Explain Pain (Moseley, Butler 2003)   3
Now that you know that your injury is more that just a tissue problem you can gradually increase your
activities without fear of worsening the problem. Identifying the amount of activity you can do before
your nervous system sounds the pain alarm is important in order to prevent flare ups whilst gradually
increasing your tolerance to activity. Following the examples below, identify three activities that cause
you pain and mark on the three lines the amount of activity you can do 1. before the point of first
feeling pain (or increase of pain), 2. before causing a flare up and 3. before further damage (This will
depend on the time since injury etc). Remember pain is designed to protect you but often the pain
alarm sounds long before there is actual tissue damage. Understanding this helps you determine how
much activity you can do without flaring up and helps you exercises without fear of further damage
knowing that the pain alarm starts to ring before further damage is occurring. You can use it to help set
goals to increase your tolerance to activity. Do this by re-writing the protect by pain, flare up lines and
tissues damage lines periodically and increasing your activity levels accordingly. It is best to work just
above the point where you first feel pain. Do not panic if you cause a flare up, simply re-evaluate where
you have placed your flare up line and re-commence pacing.

                                                                                                         1km walking
                                         Point where tissues
                                         would actually be injured
                                                                                                         100m walking
                                         Point where flare up
                                         would occur
                                                                                                         50m walking
                                         Point where you first feel

                                                                      Adapted from Explain Pain (Moseley, Butler 2003)   4
Guide                                                Activity one:___________
                        Point where tissues
                        would actually be injured

                        Point where flare up
                        would occur

                        Point where you first feel

Activity two:____________                            Activity three:___________

                                                        Adapted from Explain Pain (Moseley, Butler 2003)   5
                                                                                       Taking control
Psychological factors such as feeling in control, self esteem /feeling useful and being optimistic are
more powerful predictors of outcome/improvement after injury or pain than physical factors such
as how severe the injury was. Here are some other ways you can take control of your life and your

  Tension/Stress                                      Optimism
  Learn some relaxation or meditation                 Remember that pain does NOT = harm! And
  techniques and spend some time each day             that you can reduce your pain as you learn to
  reducing tension.                                   take control through understanding,
                                                      relaxation, the right movement and getting
  Learn to reduce tension through your                back into life.
  breathing. Keep it slow and relaxed. Imagine
  breathing out the tension.

  Activity                                            Self esteem/feeling useful
  Learn what movements, stretches and                 Feeling useful can be as simple as getting
  strengthening exercises you need to do for          more sleep to improve our mood, working or
  your body to help reduce your pain NOW              volunteering can be important here.
  when you are sore, AND to improve your
  bodies health for the future.                       Socialising with friends or family is also
                                                      primary to our sense of worth and wellbeing.
  Try to walk every day for around 30 minutes
  (you may need to spend some time building
  up to this). You could buy a pedometer and
  aim for 10, 000 steps per day.

                                                 Adapted from lecture “Group therapy for persistent pain “ 21/08/2010 UniSA   7
When it comes to pain it is particularly important not just to look after your body, but also your
nervous system, your emotional/psychological health and your immune system. Start to question
your beliefs about pain and realise that pain doesn’t always = damage and that resting is not always
the best treatment....... realise that your emotions, fears stressors, relationships and lifestyle all
impact upon your pain experience and need looking after as well............. take on the message of
pacing and begin to increase your activity levels to increase your protect by pain lines slowly but
surely........ add some regular exercise, regular laughing with friends, shake in some positive thinking
and some regular relaxation and you are on your way to taking control of your life and your pain and
desensitising you nervous system.

Butler, D, Mosely, L 2003, Explain Pain, Adelaide, Noi group publications.


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