Treating chronic pain from a Physiotherapist’s perspective involves the use of various treatment strategies.
- Strengthening the body
Part One: Glia and Mindfulness
Chronic pain is a very complex problem and understanding why your injury has become chronic can be challenging. Lots of people ask why their pain became chronic whilst someone they know who had the exact same injury healed quickly.
New research has helped with our understanding of the science behind chronic pain. One of the big puzzle pieces is something called Glia. Science used to think that Glia cells were the equivalent of packing foam or bubble wrap – that the job of the Glia was just to protect the rest of the nervous system, making up 80% of the nervous system. However, it is now understood that the glia modulates the pain neurons. So if the glia is stimulating the pain neurons, the perception of pain is increased, and vice versa – if the glia settles the pain neurons, then pain is perceived as less.
So, what causes the glia to stimulate the pain neurons?
Firstly – your emotional state. So if you are in a heightened stress response, your glia will be stimulating your pain neurons and making your pain worse. This explains why 2 people can have the exact same injury, person one is calm and heals quickly when the mechanical injury recovers. However, person 2 at the time of the injury or after, was in a personal stress state with home/financial/work stress/trauma, and this high-stress state has activated the glia and then stimulated the pain neurons. So for person 2, the path between the brain and the pain nerve becomes ingrained and the pain becomes chronic. We go into this further in Chronic Pain part 3. Another cause of glia stimulation is certain pain medications, in particular, codeine and some morphine medications. These meds may decrease your initial pain response, but then these medications also hypersensitize your pain neurons, which causes your pain to be worse. This can lead to a downward spiral as the perceived pain is worse, and so the medication dose is increased, which then stimulates the glia further, stimulating the pain neurons and making the pain worse. (If you are taking these types of medications and are concerned, please discuss your medications with your Doctor).
We can use the settling actions of glia to our advantage. Some of the ways of deactivating glia are techniques to calm and distress. If you can decrease or remove the personal stress state, then you can deactivate the glia and therefore settle the pain neurons. We suggest techniques such as mindfulness training, meditation and education on understanding chronic pain. For some people, a team of Pain Specialist Doctors, OTs, Physios and Psychologists help in this process.
Part Two: Pacing
Pacing is controlling the amount of activity that you do in a day, and over a longer time frame, such as a week, so that your activity is manageable, achievable and under the threshold of your maximum tolerance in order to prevent flare-ups of your pain.
Firstly, together we work out what are your daily tasks, and what you are currently able to complete in a day. This takes some trial over a week noting what you need to do each day and how you are feeling after these tasks.
Next, we look at what you would like to be achieving in the day and over a week – your goals. These are set with guidance from your physiotherapist and will include activities or daily living (ADLs), daily chores, work activities, family activities and fitness/exercise activities. Next, we make a plan on how we are going to get you from your current level to your goal level of activity.
Finally, we support you to achieve your goals. This process is a very gradual increase in your level of activities over time so that you are gradually pushing out your limits and achieving more, without aggravating your pain.
There are some classic traps that people suffering from chronic pain often fall into when it comes to activities. People often start to avoid all the activities that they think might make them worse. This leads to fear avoidance behaviour, and gradually you will achieve less and less, your quality of life will decline, you will become less tolerant of activity, deconditioned and weak, and ultimately you become extremely limited. The other trap is the good day- bad day scenario. That is, you have a rest day, and so the next day you feel great, so then you do all the things that day and push yourself too far, resulting in a flare-up and so the next day you rest and do very little, and the cycle continues. Both of these situations are very limiting and make it difficult to partake in a normal lifestyle. Neither of these situations will help you to manage your chronic pain.
Part 3: Focus
Focus is another strategy that we use as physiotherapists to help you manage your chronic pain. To understand how this helps, you need to understand how the brain changes when you have pain for a long time.
So, when you have ongoing pain, you get a sensitisation of the nerve pathways to the brain. Think of it as a little track through the bush – it starts out you have to clear your way through, pushing aside the branches and the long grass. But then the more times you walk through the bush along the same path, the grass becomes flattened, the pathway more obvious, the path wider. You keep using the pathway, and now you can go faster, and you can start driving your 4-wheel bike along the path. You can get there faster and easier. You keep using the path, and now the path is as wide as a car, the ground hard and flat and the trip is super quick and easy. This is what happens in your body and brain when you have chronic pain – the more the pathway is used, the easier and more efficient your brain becomes at using this track, so it uses it more and more. We call this neural plasticity, and this can be seen clearly on MRI scans of the brain in someone with chronic pain.
When we are at this point, the mechanical injury that started the process may even have resolved, but the pain highway that has become hyper sensitised and so ingrained that it continues to provoke pain responses. So the problem is the wiring of the pain pathways in the brain and at this point, we need to Re-Wire the brain.
Re-wiring the brain is retraining the brain and desensitizing the pain pathway. One of the ways we do this is to change your focus. Think about a large circle of all the activities that you could possibly do. And then think of a little circle inside the big circle, with the activities that you can currently do. Now, most people will focus on all those things outside of their little circle that they CAN’T DO. What we get you to do is to change that focus to look at all the things that you CAN do, the things inside your little circle. We focus on your actions, not your limitations and not your pain. Now gradually, with your medical treatment and using your other treatment strategies we start to increase the things that you can do, and gradually you’ll notice your little circle of achievable things starts to get bigger and bigger, and at the same time, your neural pain pathways which are now being used less frequently are starting to recover, the path in our visualisation is revegetating and returning to its normal state. This can take time, and you will need the support of your medical team along the way, but with help, you can successfully re-wire your brain, and get on top of your chronic pain. Take your life back now!
So if you feel as though this could help you out or you would like us to assess your chronic pain then come on down so we can assist you and guide you with your self-management at Lakelands and Miami Physiotherapy.