Approaching pain

Learn the various ways in which we can approach pain to take control of how our body reacts to musculoskeletal pain

One of our mind’s main jobs is to keep us alive. It’s important to stay away from danger, notice if there are threats in the world around us and be alert to these threats when appropriate. Our minds and brains are really good at finding threats in the world around us. This means things work out safer a lot of the time.

We react to all the different kinds of threats in similar ways: we feel stressed, we feel anxious and we want to get away from threat any way we can. Pain is also interpreted as a kind of a threat. We cope best when a threat is ‘out there’ or external to us. Having a threat like pain inside of us, a threat we can’t escape from, is a special situation that challenges us, making it difficult to cope.

When we have chronic or persistent pain, we can feel trapped with a threat we can’t seem to escape. The most natural thing is not to want the pain. Our mind tries harder and harder to tell us about the problem with feelings of anxiety or of distress. We start feeling trapped with the pain too and just wish we could escape.

Our mind gets better at finding the pain and telling us loudly that it’s still here: we fail to escape. The mind gets better at detecting the pain and tells us about pain using a louder and louder ‘voice’, constantly calling attention to the pain. The more anxious and threatened we feel about our pain, the more threat-sensitive parts of the brain turn on. And, this can actually turn up our ‘pain volume’ button a lot.

How can I turn the pain 'volume control' button down?

Try these 4 quick and easy steps:

  1. Slow down, pace yourself
  2. Stop & stare – remember that it’s pain, it’s not fun, but it’s not dangerous
  3. Breath in slowly and deeply – allow yourself to feel heavier as the air leaves your body
  4. Remind yourself that pain is like information in the body – it has no claws & no teeth, there is no tiger.

Distress and pain

You need to take some pressure off the body and the mind. It is important to accept that you will have some pain each day. Schedule and DO a consistent amount of paced activities and relaxation.

Associations between pain, movement & distress become a linked chain, but when you move less, your life gets smaller. Accepting pain is an important step towards better managing your pain and reducing your distress. This means you can cope better over time and live a life that is more meaningful for you. Accepting pain rather than elevating the importance and dominance and setting up your attitude to cope with whatever is helpful. Acceptance does not mean giving up hope.

Practical tips to manage distress

  • allow yourself to notice pain sensations and don’t be afraid of pain. Pain is difficult, not dangerous
  • notice your body response to pain. You might not get much say in the pain level from moment to moment, but you can choose less distress by focusing on breathing and relaxing
  • learn how to fail to feed pain with distress - don't feed the tiger; don't even accept that there really is a tiger!
  • step back from pain and stop labelling it to decrease its importance. Stop fighting with what has happened & decide to work with the pain to manage it.

Remember: Working with your pain takes less energy and stress than fighting against it. You need to reduce distress about pain to retrain your mind to pay it less attention. Relaxation trains the mind to understand that your persistent pain is not dangerous.

Managing pain so you can live well, means you need to work smarter, not harder. Listen to our approaching pain relaxation example below and follow the instructions to help you learn how to train the brain to relax. You can download this relaxation example file, so feel free to use it as often as you like.

8 tips to help you better cope with your pain:

  1. try to soften yourself to pain rather than fighting it – fighting it is like putting petrol on a fire
  2. try and find the grey areas rather than thinking in ‘black or white’
  3. when pain grabs your attention – try using the natural breath: slowly breathe in for 5 seconds and then slowly breathe out for 5 seconds
  4. when your breathing has slowed, try moving your attention back onto the things you need to do
  5. ease back into doing the things pain pushed out of your life. Setting small goals that you can achieve now, TODAY, is important. Enjoying the small things – goal setting so you can achieve your goals
  6. the slower you go the faster you will get there. Setting goals for today is a good start. You can also start to think ahead to where you will be in a few weeks or a few months time starting now to slowly change things will allow you to come out in a better place over time
  7. pushing too hard, too soon isn’t smart any more – you will need to find the ‘grey’ areas, and accept that you will need to gradually build up, to strengthen yourself both physically and mentally
  8. be your own best friend – cracking the whip over yourself when you are already struggling is punishing. Be gentle with yourself. Go easy and try and congratulate yourself on one achievement each day

Getting help for your mood

It seems that the mind/brain drops our mood on purpose to stop us from staying too long in a difficult or unpleasant environment.

Helpful Thoughts

  • focus on the things you CAN do today
  • choose to spend time here and now: doing things you need to do, or love to do, is healthier than minutes spent with unchangeable problems in your mind
  • if your mood is low, then your tolerance of pain is less
  • it is common to stop doing things you enjoy because pain is unpleasant
  • the unpleasant pain experience punishes you, and at the same time, if you are doing less rewarding things, then there are fewer positives in your life
  • think about the see saw principle: when you have more difficult or unpleasant things (called ‘punishers’) in your day, the see saw goes down and your mood drops. When you have more enjoyable or pleasant things (called rewards), the see saw goes up and your mood lifts.

Helpful things to DO to manage your mood

  • DOING is good, even the small stuff
  • increase the positives in your life to helps balance ‘up’ your mood
  • walk daily, spend time with people, start and finish something every day (get shopping done or pay a bill), and put the things you love into each day on purpose
  • write down what things annoy or upset you the most (including the pain)
  • work on the things that you CAN do something about
  • get whatever help you need from family members, your GP or a psychologist
  • get back to doing pleasurable things that pain took away by making goals & working towards them.

Relaxation can also help you better manage your distress and reduce your pain. Relaxation needs practice, just like muscles need movement and exercise to function well. Try our mindfulness and pain training module to help you get started and get some tips.

Remember: Issues that can't be worked on, or solved any time soon, need to get less of your thinking time. Each minute you spend running through the problems in your head, makes you feel bad again and pushes your mood down. Use the '3 D’s approach'.

The three D's approach

  1. Do it
  2. Dump it
  3. Delegate it.

Depression

The symptoms of what we call ‘depression’ are descriptions of the ways that we tend to react when surrounded by problems; how we try to withdraw from the world when it feels bad for too long.

Even small drops in our mood can turn up the ‘pain volume’ button. So it’s important that we do something about mood, if we want to control the pain volume. While not everybody with chronic pain gets depressed, ongoing pain always puts pressure on our mood.

Your mood (how you feel) can take a beating when you have persistent pain, and this is a common experience, but it’s not good to let it get out of hand. If you are concerned about your low mood, please discuss this with your doctor or health care professional as early as possible. Low mood can delay your recovery from pain. If you find you have no fun and no energy in your day and you are irritable a lot of the time, then your mood might be low.

Making a plan to do the things you care about is helpful – this gives you structure and certainty in your day. Do a little every day, pace yourself and remember to take breaks. Not everyone with a pain problem gets depressed, but people with pain usually have a fair bit to deal with and that will put pressure on their mood. When mood drops it has a direct impact on pain, it’s another thing that turns the pain ‘volume control’ button up.

The key to better managing your mood and pain is to try and work out the parts of your pain condition you can address and which are the main triggers for your pain. You may like to draw a pie chart and allocate the “pieces of the pie” (mood, depression, anxiety, fear, distress, poor coping, anger, frustration) that are part of your pain condition and that need management.

Rather than tackling all pieces of the pie in one go, try setting your focus on 1 or 2 small achievable goals. Here is an example:

  • establishing a good sleep and exercise routine is essential to helping to get you back on track. Developing a regular sleep time and routine will reduce your pain. Using a low dose anti-depressant may help you to regulate your sleep: discuss this with your doctor
  • improving your sleep routine is a great start to better managing your pain. Improved sleep means less pain and allows you to undertake carefully paced activity and exercise
  • exercise and activity help to engage your body’s own pain control medicine chest and boost your mood and immune function and de-sensitise your nervous system: this means you can effectively turn the pain ‘volume control’ button down
  • so, rather than using a single approach (like medications) to mood control, you have coupled up a few simple strategies (sleep, and paced activity and exercise and possibly medication). This combined or ‘multimodal’ approach can make a big difference to your pain over the days and weeks

There are also some online training tools available to you through Beyond Blue.

Anxiety

If you feel jumpy, your heart races at times, or if it feels like something is about to go wrong a lot of the time, you might be struggling with anxiety. Remember when you are in pain, pain is interpreted as a threat and it can turn the anxiety parts of the brain ‘on’ – this often means the pain ‘volume button’ is turned up.

One of the things that can increase anxiety, is feeling that there are so many things to do and you just can’t manage them all. It’s easy to feel overwhelmed and trapped in this situation. Managing your approach to the day-to-day demands is a vital part of managing pain.

Here are some helpful tips:

  • achieving one thing each day will help you feel like you are making progress
  • try and focus on fewer things and get them done in smaller chunks or bites: this means using a paced approach
  • it is important to make some spaces in your day, where it’s not “all go, all the time”. You need to relax before you have pain, and you need relaxation more when you have pain
  • if you have work, financial or personal issues hanging over you then it is worth the effort of tackling these issues rather than letting them gnaw away at you. Avoiding things still puts pressure on you
  • having more ‘load’ from issues that are unresolved will really push anxiety up and amplify your pain. You are better off doing the hard work of addressing these problems, than the hard work of not addressing them and experiencing the negative impact of more pain
  • if the demands that other people place on you is a part of your anxiety, letting them know the effect of this on you is important. Most people are willing to try and improve such situations
  • remember, in some ways the whole family has got a pain problem. And sometimes other family members might not realise how much it is affecting them too. Talking about these things with your family and friends is really important
  • if you can agree the family’s priorities, and include family members in helpful aspects of your pain management like pacing your exercise and activity, you will do much better.

Professional help

Getting back to a life you love is the goal of treatment. Getting help to achieve that is a great idea. However, when dealing with the mood issues, anxiety, how to manage your load or work better with your family, you don’t need to do it alone!

Seeking help from your GP, from psychologists, from physiotherapists or a pain service could be a really important support. The right advice and help at the right time could have a big impact.

Getting help from a psychologist

Psychological approaches, as part of multidisciplinary care, are amongst the most effective approaches to persistent pains such as low back pain1.

Psychological therapies that cover the topics described above are also effective treatments by themselves: these approaches can help in modestly reducing pain, improving physical functioning, and improving negative emotional aspects of pain like depression and anxiety2.

The type of psychological therapy that has been studied most and has the most evidence for treating persistent pain is called Cognitive Behaviour Therapy (CBT). This treatment is usually delivered by a psychologist, and helps you to develop self management skills to:

  • reduce negative thinking, increase the amount of enjoyable activities in daily life
  • reduce stress with relaxation techniques, solve problems more effectively
  • communicate better with those around you

A new wave of psychological therapies also shows similar promise in helping people live more meaningful lives when dealing with pain. Acceptance and Commitment Therapy (ACT) is one of these approaches. ACT shares many similarities with CBT, but focuses especially on setting goals for activities that are important for you. ACT helps you to learn how to reduce the impact of negative thinking using mindfulness.

These two approaches – CBT and ACT – seem to be equally effective for people in pain3, and suit people differently depending on preference and both can be done in a group setting or individually.

Treatments focused mainly on developing greater mindfulness through the practice of meditation may prove as effective as CBT and ACT4,5. For more detailed information about this, see our pain management module on mindfulness meditation.

You might benefit from trying these psychological approaches to pain management. Being referred to a clinical psychologist does not mean the pain is not real or that it is ‘all in your head’. Ask your doctor or seek professional guidance from a psychologist with training and experience in this area. Ask for recommendations from trusted sources and enquire about the psychologist’s treatment approach and experience with helping people in pain.

Clinical Psychologists are most commonly involved in pain management, while Health Psychologists and Counselling Psychologists often have experience in this area too.

What about medications and mood?

Medication can assist in helping you to control your mood but are not recommended as a standalone treatment. Medications are most often used to help you engage in exercise, activities such as work and social engagements and to get a good night’s sleep.

You can find more information about medications from our medicines and procedures training module.

Further Information

For more clinical information about anxiety and depression, we recommend going to This Way Up. For information about managing mood and anxiety, we suggest Beyond Blue. You can find consumer summaries though Cochrane Summaries. Alternatively, if you need to speak to your GP or health care professional, please seek further assistance.

This Way Up - How we can help

eCentre Clinic - Pain course

Australian Psychological Society - Find a Psychologist

painHEALTH - Approaching pain podcast

  1. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj 2015; 350: h444. [PubMed]
  2. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. The Cochrane database of systematic reviews 2012; 11: CD007407. [PubMed]
  3. Wetherell JL, Afari N, Rutledge T, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain 2011; 152(9): 2098-107. [PubMed]
  4. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain medicine 2013; 14(2): 230-42. [PubMed]
  5. Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain 2011; 152(3): 533-42. [PubMed]

This module has been developed by Carl Graham, BSc(Hons), MAPs; Clinical Psychologist, Fremantle Hospital and Health Service, Perth, Australia, Rob Schütze, BA, BJourn, BSc(Psych)Hons, MPsych(Clinical), Curtin University and Wisdom Health; Adjunct Associate Professor Stephanie Davies, MBBS, FANZCA, FFPMANZCA, Pain Medicine Specialist, WA Specialist Pain Services, Perth, Australia and Helen Slater, PhD, FACP, Specialist Musculoskeletal Physiotherapist, Associate Professor, School of Physiotherapy, Curtin University, Perth Australia.


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