Pain is defined by the International Association for the Study of Pain, as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. This is the revised IASP definition as of 2020. Pain is one of the body’s important alarm systems, designed to protect us and warn us that we are under threat. When a person experiences pain, one of the most natural responses is for that person to give attention to where the pain is coming from, or discover what is causing the pain or threat. When you experience acute pain, the problem usually relates to local tissue injury, infection or inflammation. However, with chronic pain, the problem is often less strongly related to local tissues and involves a broader (systemic) problem. In acute pain most of the “receptors” (called nociceptors) tend to be mainly localised at the site of any infection, inflammation or injury – the body’s systems are designed to recognise the injury or damage and coordinate the mind and body to favour recovery. In chronic pain, things change: there is growing involvement from other body systems (for example, the immune system, the sleep system, the hormonal system, the endocrine system). Changes occur in the way in which the nervous system interprets normal input or information: things that might cause pain normally, can cause much more pain and things that don’t normally hurt (e.g. normal daily movement or activities, gentle touch) can actually be painful. This is because the nervous system is not hard-wired but plastic, and the changes are due to the neuroplasticity of the nervous system and other systems, including the immune and endocrine systems. These neuroplastic changes in the nervous system contribute to ongoing pain. While treatment and management of acute pain may be more focused on the immediate tissue injury or the illness initially, treatment and management for a person with a chronic pain problem must also address broader body-mind systems (for example, immune, nervous, hormonal, behavioural and emotional contributors to pain. Credits: Credit: Joyce McSwan - PainWISE Pty Ltd Royal Perth Hospital (EMHS)

About pain medications The name ‘pain killers’ tends to give the wrong idea. Pain medications called ‘analgesics’ or pain modifiers, and most pain procedures, only tend to help about 1 person out of 4 improve their pain by 50% (or more), compared to a placebo or dummy treatment. So if a pain medication is given to 4 people, one person will get 50% or more relief (compared to placebo). Hence, the name ‘pain modifier’ is more realistic than ‘pain killer’. It is best to keep your expectations low! All medications and procedures have a placebo (or ‘I will please’) effect: this shows the power of our body to control pain naturally, and is a good thing. Placebos have a positive effect, as our bodies are ‘wired’ to release our natural pain modifiers. If you do get a positive benefit from pain medications or procedures, make sure you continue to advance your paced activity and keep moving with pain. This approach helps to prevent a recurrence of your pain. The goal of pain modifying medications is to allow you to get active, to improve your physical function, mood, sleep and your ability to manage your pain. Sometimes your doctor may advise combining medicines. This is because different drugs work at different places in your body and in different ways. Combining drugs can mean you require lower doses of each, with less risk of side effects while ensuring pain relief. Credits: Royal Perth Hospital (EMHS). Joyce McSwan - PainWISE Pty Ltd

Exercise is medicine. Relaxed movement and physical activity are vital to helping you manage your pain so you can do the everyday things that are important to you1. Think for a minute about spraining your ankle or your back: when we experience acute pain, especially when it is distressing, one of the body’s natural responses is to initially tense up and limit movement, in order to protect the body. This protective response is usually short-lived (24-48 hours), but can be unhelpful in the longer term if it persists. Research shows us that movement, activity and exercise can be very helpful to reduce pain and improve function for people with musculoskeletal pain. Even if you have a medical condition like osteoporosis or have had surgery for back pain, movement, activity and exercise form a key component of your recovery. Recent evidence on lower limb osteoarthritis shows that compared with no exercise, doing exercise (such as strengthening exercise) significantly helps reduce pain. The size of the benefit (known as the ‘effect size’) is much larger than the largest benefit shown for paracetamol in hip or knee osteoarthritis. In this context, exercise can be considered ‘medicine’. Improving function (e.g. our ability to engage in daily activities such as household tasks, work, study, socializing etc.) through movement, activity and exercise has profound beneficial ‘flow-on’ effects, including reduced disability, reduced depression and improved physical conditioning and increased quality of life. This module is focused on integrating movement with all the “pieces of your pain jigsaw” to help you move in ways that reduce fear, pain and improve your functioning.

Food and Pain

Sleep problems and chronic pain seem to go hand in hand. Frequently people with chronic pain find it difficult to fall asleep, or sleep is often disrupted with long night awakenings. Even if you get a good amount of sleep, you can still feel very tired in the morning as the quality of sleep is often poor. Because of this, it is common for people to want to address sleep as part of pain management. Having a bad night’s sleep can make you feel more pain sensitive. Pain and sleep are closely linked and impact each other. There is a reciprocal relationship where pain during the day affects the quality of that night’s sleep and poor quality sleep increases pain levels the next day. In fact the latest findings point to sleep effecting pain levels greater than the other way round. So it is important to try and give yourself the best chance of having as good sleep as possible.

Chronic pain can be one of the most debilitating conditions in daily life. Chronic pain goes beyond the pain itself. The mental stress and biologic psychological effects of pain can be just as severe as the pain itself. In fact, people with chronic pain are three times more likely to develop depression. If you’re suffering from chronic pain and have noticed an increase in irritability, mood fluctuations, and other psychological issues, you’re not crazy. Pain is inextricably linked to emotions. In fact, physical pain and emotional pain exist on almost the same circuitry of the nervous system, with common brain systems involved. For this reason, it’s not surprising that the presence of chronic pain is often associated with emotional changes. Anxiety associated with chronic pain is real. As a stressor, the natural response is to escape or flee the pain. However, with chronic pain, this is often not possible. Even in times where the pain is not present, chronic pain sufferers may experience anxiety surrounding the return of the pain. This anxiety can be crippling and detrimental to the quality of life. The link between chronic pain and depression is strong, but it’s not well understood by psychologists. Some researchers believe this depression as a result of pain may be programmed into our wiring evolutionally. Contextually, it makes sense. Withdrawing from society provides the body with a peaceful environment that is needed to heal. It also creates a “safe place” away from stressors and possible threats. However, chronic pain makes this difficult because the threat is internal, not external. The result can be chronic, nagging depression that seemingly has no end. Depression-like symptoms may also evolve as a perception of loss of control. This is called adjustment disorder and results when an individual fails to adapt or cope with a perceived stressor like chronic pain. However, depression is not necessarily a guaranteed progression in chronic pain. It is impacted by a number of factors, including genetics. Credits: Psychological Association Inc. Joyce McSwan - PainWISE Pty Ltd