What Would You Do If You Had Less Pain? (Part 2)

 

  1. Spend More Time with Loved Ones
  2. Travel
  3. Be More Independent
  4. Enjoy Life More
  5. Be In a Better Mood

6. If you answered Spend More Time with Loved Ones, it is clear that family and friends are a top value for you. You may feel you aren’t doing your part in the relationship. Perhaps, you say, “I don’t want to slow them down” and so you miss out on fun events with them. Or are you used to being the caregiver in your family? Maybe you withdraw from other because you are uncomfortable asking for help.

Solution: Withdrawing from people you love doesn’t usually help with pain in the long run. However, taking self-care breaks or setting healthy boundaries with loved ones is a necessity for a good life even for those without chronic pain. It is tempting to put fun activities or strengthening relationships on hold until pain decreases, but this may result in more strained relationships and cause you more pain in the end. If taking care of others is important to you, pain might be a signal for you to find more balance between taking care of others and your own self-care. Don’t jump back in at full force, but show up when you can and participate in a way that works for you now. As for not slowing them down – they likely value you for who you are, not what you do. You might value yourself the same way and let them decide if they mind being slowed down.

7. If you chose Travel, it is likely you have an adventurous spirit, have traveled before and know the gifts of perspective, beauty, and excitement that travel can bring. Avoiding travel is a common mistake for those with chronic pain. If your condition is stable and chronic (not rapidly worsening, deteriorating, or waiting for surgery), you have likely been given permission by your doctor to travel, but it’s fear of pain that keeps you at home. You wonder what will happen if you have a terrible flare up on vacation and so decide to remain home.

Solution: What would happen if you had a flare-up on vacation? What is the worst thing that could happen? Be aware of how much fear is driving your decision to avoid travel. Pain can be awful and we want the comfort of home, but a flare is a flare. You may be out of your comfort zone experiencing a flare, but this is not something you can know for certain in advance. Our expectation is to feel our best on vacation. The reality is you might not, but don’t let this deter you from doing something you enjoy. You can bring pain with you anywhere — fortunately and unfortunately.

Challenge yourself to set up your trip for success. Thoughtful preparation will help. Be creative using supportive devices like canes, walkers, back supports, ice and heat packs to ease your ride. Work on conditioning yourself, eating right, sleeping well, and minimizing medications before you go. Creatively schedule the details of your trip to pace events such as sight-seeing, hiking, sitting, and build plenty of opportunities for rest and gentle movement into your itinerary. Take more time to go shorter distances. A slow, steady rate may take longer, but you may discover things otherwise missed on the journey.

8. If you said Live More Independently you may be grieving some of the personal losses that go with chronic pain. It is likely that you have been forced to give up some independence such as working, driving, or engaging in projects around your home. Adjustment to these losses certainly takes time and patience. It may be especially challenging if you are used to taking care of others and now you need help taking care of yourself.

Solution: Being truly self-sufficient is more of a myth than a way of life. Wanting to be alone too much may even be a sign of depression. Being interdependent, rather than independent, is how we survive as a group. It is very challenging to let go of control and let others help. Pushing yourself in an attempt to maintain complete independence can lead to misery. Eventually, it negatively impacts your well-being and the well-being of those around you. How do you feel when you help others? Likely, you enjoy it. What would it be like to afford them this same gift?

Chronic pain and limitations can be a catalyst toward recognizing the gifts that come with asking for help and relying on others. When you need help, use your energy to do what you can without fighting against yourself or others. Be realistic about what you can and cannot do and communicate clearly with those around you. All-or-nothing is not the best option. Try picking and choosing those activities you can still do safely on your own.

less pain9. If you chose that without pain you would Enjoy Life More, there seems to be no argument! Agreed, life would be more enjoyable without chronic pain and if that was possible, I would be selling the cure in bulk. But what will life be like for you if you wait to enjoy it only after pain goes away?

Solution: Any wish for suffering is unhealthy. However, pain is already here so we may as well recognize the gifts that can come with it. It can be a great teacher — not just a disciplinarian. It seems like everything would be better without pain, yet some people who have suffered greatly say that suffering was a gift that brought other beautiful things with it. Without the struggle, they would have missed out on the growth. This is not to say that you should start enjoying pain or be grateful for pain…that’s just crazy. Or is it?

Could we dare to be grateful for pain as we lean in to hear what it has to say? Might it have messages reminding us that we are human and to slow down, to prioritize our values, to take better care of ourselves, to lean into discomfort, to forgive, to share, to ask for help, to empathize, to be brave and stare it in the face, move through it rather than away from it — yes, even befriend it? This is the ultimate challenge in your relationship to pain. What would it be like to befriend yourself with pain? What would you lose if you stopped fighting pain?

10. If without pain you would Be In A Better Mood, you likely have insight into how pain and mood can impact each other. You may have noticed how irritable you become, or even that you can lash out at loved ones — and it justifiably bothers you. Pain can certainly take up so much space in our brains that we feel worn out, irritable, and as if one more thing will tip us over the edge. You may have thought, “If only pain would go away, I could be a nice person again!”

Solution: You may have already noticed that your mood is impacted by how your body feels, but did you know that your body also holds emotions in it and that your moods affect pain? Although the brain is the control center for your body and its sensations, emotions also reside in the body. Do you know where you feel frustration in your body? Where do you feel anger physically? What about impatience, fear, helplessness, loneliness, or sadness? Check your body when you are experiencing different emotions to see where you personally hold these feelings. Is it your shoulders, stomach, back, hands, jaw or forehead? Sooth your mood and pain at the same time. Try to move straight through discomfort and other strong emotions. Find small joys and comforts in the ordinary. Search for wellness by asking yourself, “What is right with my body today?” Be loving and patient with yourself and you may find that you are more patient with others as well.

Date of last modification: 10-20-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

Stress and Chronic Pain

“Why do you guys always want to know how much stress I have?” While the patient who asked this question the other day had fibromyalgia, she could have had chronic low back or neck pain, chronic daily headaches, complex regional pain syndrome, or any other chronic pain condition. She was expressing a sentiment that I often hear in one form or another. It goes something like the following: ‘I’m hear to talk about my pain and what we can do about it, but you ask me about all these things that are unrelated to pain, like whether I worry, whether the worry keeps me up at night, what’s going on at home, whether my spouse believes me that I hurt as much as I do. In effect, I’m here to talk about my pain but you want to know how stressed I am. Why?’

It’s true. Providers who specialize in chronic pain rehabilitation always evaluate the patient’s pain, of course, but they also always assess the stressful problems that the patient experiences. To the list above, we might add such stressors as depression, anxiety, past trauma, sleep problems, persistent problems with concentration and short-term memory, financial problems, loss of the role in your occupation or family, the loss of sexual and emotional intimacy in your relationship, and the list could go on. All these problems cause stress, which is why we call them stressors. Why is it important to deal with stressors when having chronic pain?

There are a number of reasons why it is important, but let’s review two today:

  • If you can’t fix the pain, you might as well work on reducing the problems that occur because of the pain.
  • To successfully self-manage chronic pain, you have to manage your stress.

Let’s look at these reasons one at a time.

Stress caused by pain

Understandably, patients with chronic pain want to focus on how to reduce pain. To some extent, this focus is helpful. There are indeed a number of lifestyle changes, such as mild aerobic exercise and regular relaxation exercises, which, when done over time, can reduce pain. There are some medications, such as tricyclic antidepressants and antiepileptics, which have been shown to reduce pain too. However, these treatments are only so effective. We really don’t have any treatments that are super effective for chronic pain. (Procedures, such as injection therapies and spine surgeries, are known to be largely ineffective, despite how often they are pursued.) At the end of the day, chronic pain is chronic. It’s not ultimately fixable. While some of things that can be done to reduce chronic pain are helpful, they are only mildly so.

Given this fact, if you can’t fix the pain, then you might as well work on the problems that occur as a result of the pain. It’s possible to have chronic pain and not have it disrupt your life. It’s possible to have chronic pain and not be depressed about it. It’s possible to have chronic pain and sleep well at night. It’s possible to have chronic pain and work full-time. It’s possible to have chronic pain and have a fulfilling and intimate relationship.

Now, many people have to learn how. But, if they are open to learning, they can learn to self-manage pain well enough to be able to overcome these secondary problems. Such learning can take time and practice. It also takes a certain amount of devotion to maintain lifestyle changes, once you learn how to do them. Nonetheless, it is possible.

What patients learn could be called stress management and it involves cognitive behavioral therapies.

Good self-management of chronic pain involves stress management. When you overcome depression, even if chronic pain remains, it’s still a win for you. When you come to sleep well at night, after a period of chronic insomnia, life gets better, even if you continue to have chronic pain. When the strain in your relationships subside, your marriage and family life deepen, making life more meaningful and fulfilling, despite having chronic pain.

Overcoming the stressors in life, even when they occur as a result of chronic pain, is a way to get better when there is no cure for the pain itself. Patients with chronic pain might initially wonder why chronic pain rehabilitation providers want to focus on the stressors in their life, but from here we can see why. It’s a way to get better when there is no cure. If you can’t fix the pain, focus on overcoming the stressful consequences of living with pain. By doing so, you make life easier and better.

You also make the chronic pain more tolerable by coping better with it. By overcoming your depression or anxiety, everything in life gets easier to deal with – pain included. It becomes more tolerable. When you sleep reasonably well, on most nights, you deal with everything better – pain included. It becomes more tolerable. The same is true with any of the stressful problems that go along with living with chronic pain. When you overcome them, you cope better with the pain itself. By focusing on reducing stress, you come to cope better and pain can go from what was once intolerable to what is now tolerable.

Chronic pain rehabilitation is the form of chronic pain management that most focuses on helping patients to overcome the stress of living with chronic pain and thereby cope better with pain. The other forms of chronic pain management – spine surgery clinics, interventional pain management clinics, medication management clinics—focus mostly on reducing pain, and not on the stressors that occur as a result of pain. Chronic pain rehabilitation programs focus on both. They provide empirically proven methods to reduce pain, while also providing therapies to overcome depression, anxiety, insomnia, cognitive deficits, relationship problems, and disability.

Stress management and chronic pain management

We just saw how overcoming stressors related to pain makes life easier and better, even though you continue to have chronic pain. We also saw how overcoming stressors can lead to better coping, which, in turn, makes chronic pain more tolerable. Doing so, however, is important for another reason: managing stress well also reduces pain itself.

We all know that stress makes chronic pain worse (Alexander, et al., 2009; Flor, Turk, & Birbaumer, 1985). No matter what the original cause of your pain, stress exacerbates the pain. You have probably noticed this fact.

Whether it’s from depression, insomnia, relationship or financial problems, stress affects us by its effect on the nervous system. Stress makes us tense and nervous – literally. Our muscles becomes tight, particularly in certain areas of the body – the low back, mid and upper back, shoulders, neck, head, forehead, and jaw are the most common areas (we also feel it in our gut, by the way, with upset stomachs, reflux, diarrhea, among other things). Over time, the chronically tense muscles can ache and spasm. In other words, the persistent stress that results from chronic pain can cause chronic muscle tension, which, is painful.

Chronic pain causes more pain! It does so through the stress that it causes, which subsequently activates the nervous system and the persistently stressed nervous system leads to chronic muscle tension, which becomes painful in and of itself.

When understanding the role of stress from this perspective, most every chronic pain patient readily understands it because they live it. They see how stress affects their pain levels from their own experience.

Stress and its effect on the nervous system can exacerbate pain through more direct routes too. It’s not just the effect that stress has on muscle tension. It’s harder to see from your own personal experience, however, and so you’ll have to rely on a more textbook-like explanation. Stress, particularly the persistent stress of problems that occur as a result of chronic pain, causes changes to the nervous system itself. These changes occur in the spinal cord and brain and they result in changes in how sensory information is processed. An example of sensory information is pain signals that travel from nerves in the body, through the spinal cord, and up to the brain; the brain subsequently processes this information and the experience of pain results. As a result of persistent stress to this system, the brain comes to process such information with greater and greater sensitivity and as a result less and less stimuli (i.e., sensory information) is required to experience pain (Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Imbe, Iwai-Liao, & Senba, 2006; Kuehl, et al., 2010; Rivat, et al., 2010).

It’s generally accepted that by overcoming the persistently stressful problems that occur as a result of living with chronic pain – such as insomnia, depression, anxiety, you can make some headway in reversing these changes. You might not be able to change them entirely, but enough to reduce the pain itself. Indeed, most providers would concur that to adequately manage chronic pain these kinds of stressors must be addressed (Asmundson & Katz, 2009; Kroenke, et al., 2011; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009).

Concluding remarks

In all, good stress management is essential when it comes to successfully self-managing chronic pain. There is only so much that can be done to reduce pain when you have chronic pain. The most effective therapies we have for chronic pain are at best only mildly or modestly helpful at reducing pain. There is, however, no end to how well you can get at managing the stressors that result from chronic pain. It’s possible to overcome depression or anxiety or insomnia or relationship problems or any other stressor, even if you continue to have chronic pain. Now, these problems are not easily overcome. They take work and motivation and perseverance. Nonetheless, it is possible. By doing so, you get better. Pain becomes more tolerable too. In fact, by reducing the amount of stress in your life, you also reduce pain itself.

It’s for all these reasons that your healthcare providers keep wanting to focus on the stress in your life, in addition to the chronic pain in your life.

References

Alexander, J. K., DeVries, A. C., Kigerl, K. A., Dahlman, J. M., & Popovich, P. G. (2009). Stress exacerbates neuropathic pain via glucorticoid and NMDA receptor activation. Brain, Behavior, and Immunity, 23(6), 851-860. doi: 10.1016/j.bbi.2009.04.001.

Asmundson G. J., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety, 26(10), 888-901.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173.

Castillo, R. C., Wegener, S. T. , Heins, S. E., Haythornwaite, J. C., MacKenzie, E. J., & Bosse, M. J. (2013). Longitudinal relationships between anxiety, depression, and pain: Results from a two-year cohort of lower extremity trauma patients. Pain, 30. doi: 10.1016/j.pain.2013.08.025.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S.  (2006).  Central hypersensitivity in chronic pain:  Mechanisms and clinical implications.  Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Flor, H., Turk, D. C., & Birbaumer, N. (1985). Assessment of stress-related psychophysiological reactions in chronic back pain patients. Journal of Clinical and Consulting Psychology, 53(3), 354-364. doi: 10.1037.0022-006X.53.3.354.

Imbe, H., Iwai-Liao, Y., & Senba, E.  (2006).  Stress-induced hyperalgesia:  Animal models and putative mechanisms.  Frontiers in Bioscience, 11, 2179-2192.

Kroenke, K., Wu, J., Bair, M. J., Krebs, E. E., Damush, T. M., & Tu, W. (2011). Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care. Journal of Pain, 12(9), 964-973. doi: 10.1016/j.jpain.2011.03.003.

Kuehl, L.  K., Michaux, G.  P., Richter, S., Schachinger, H., & Anton F.  (2010).  Increased basal mechanical sensitivity but decreased perceptual wind-up in a human model of relative hypocortisolism.  Pain, 194, 539-546.

Rivat, C., Becker, C., Blugeot, A., Zeau, B., Mauborgne, A., Pohl, M., & Benoliel, J.  (2010).  Chronic stress induces transient spinal neuroinflammation, triggering sensory hypersensitivity and long-lasting anxiety-induced hyperalgesia.  Pain, 150, 358-368.

Vachon-Presseau, E., Roy, M., Martel, M., Caron, E., Marin, M., Chen, J., Albouy, G., Plante, I., Sullivan, M. J., Lupien, S. J., & Rainville, P. (2013). The stress model of chronic pain: Evidence from basal cortisol and hippocampal structure and function in humans. Brain, 136, 815-837. doi: 10.1093/brain/aws371.

Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 5(4), 355.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-4-2013