Your treatment journey

Medical help for pain

When it comes to persistent pain, evidence suggests that medication, injections and surgery may have quite limited or short lasting effects. This is not to say that these options do not have their place but we would always encourage patients to use medication alongside other non-pharmacological treatments rather than becoming reliant on drugs to manage pain long term. Once serious medical causes of pain have been ruled out, it is usually the non-medical options that are most effective at least in the longer term. However, not all pain is the same and different drugs work on different parts of the nervous system so it might be useful to continue to explore medical options (in the short term) rather than give up because the first thing you have tried did not help.

Oral medication or injections can provide a useful window of opportunity for many patients allowing them to engage more effectively in their physical rehabilitation. Unfortunately, medical treatment for pain is often done in isolation or alongside brief or ineffective physical rehabilitation. The key here is to ensure good communication is maintained between all members of the clinical team.

Surgical options, particularly for persistent back pain, can often result in poor outcomes; if you have persistent spinal pain and are considering surgery we would recommend a second opinion and to fully explore all other options before committing to this.

We fear pain when we do not understand it

It all starts with education. Good quality research shows that developing a more accurate understanding of pain is actually one of the most effective ways to treat it. We each have our own unique, subjective conscious experiences. Patients with persistent symptoms often have quite inaccurate ideas about the meaning of pain. Developing a more healthy and accurate understanding of pain often enables patients to reduce the fear of harm that can be associated with movement. This allows the nervous system to re-calibrate so that we feel pain only when it is appropriate and helpful rather than when the body is actually out of danger and continued symptoms are no longer useful. We sometimes refer to this aspect of treatment as Pain Reprocessing Therapy.

For many patients, providing this basic reassurance can have a really significant effect on their pain. For others, perhaps those with a more fixed mindset, more subtle therapy is required to help. More in-depth discussion is used to challenge patients beliefs about their symptoms in relation to perceived wellness and ‘body integrity’; we refer to this as cognitive behavioural therapy (CBT) for pain. For some patients with deeper emotional issues affecting their symptoms, more involved psychotherapy techniques can also be useful.

Develop your cognitive flexibility

Cognitive behavioural therapy (CBT) for pain takes the initial education a little further. It explores the interactions between our thoughts, emotions and behaviours in relation to bodily symptoms for patients who are struggling to process what is going on. It gets patients to challenge how they perhaps think about themselves in relation to their symptoms. An example of this might be, ‘I have pain in my back and do not understand why. Attempts to treat my back are not working and now I am worried. I have become concerned that if I do the ‘wrong’ thing I might make my situation worse and I’ve become scared to move. I worry that my body is not physically capable anymore and no longer trust it to do normal things. Now I feel limited in what I can do with my life and I feel down. It is starting to affect my relationships at work and with family’ .

Persistent pain is often something we see more in patients who have somewhat fixed, and perhaps slightly inaccurate, beliefs about their body integrity and health in general. We encourage patients to improve their ‘cognitive flexibility’ and adopt more accurate ideas about their pain and their body. This can be tricky but an area that allows many patients to transform how they feel.

It’s not what you do but how you do it

Pain motivates us to change our behaviours. This could be something as simple as moving your hand away from a very hot object, an example of a useful or ‘adaptive’ response. But pain often changes our movement patterns and habits in ways that are ‘maladaptive’ or unhelpful. Avoidance of movement altogether or compensations away from more ‘ideal’ postures and movements towards ones that are less efficient (often overly protective) can be one way in which physical stress keeps tissues feeling more sensitive than they should. This is not to say that there is one ‘correct’ way to move and that alternatives are bad, just that moving more efficiently will tend to create less ‘noise’ in your nervous system for the brain to interpret (or potentially misinterpret). Most patients, even with quite chronic back pain, find that more efficient movement immediately feels more comfortable. ‘It’s not necessarily what you do but how you do it that counts’.

Cognitive Functional Therapy (CFT) is a large part of this stage of treatment and involves learning to move without fear and without the overly-protective and guarded movement habits we see in many patients that actually helps maintain their symptoms.

Get back to doing the things you love

Once patients have learned more optimal and comfortable movement strategies and are continuing to understand that pain does not necessarily signify danger to our body tissues, we encourage people to move more and get back to the things they love doing again. Movement is a fundamental and necessary part of what it is to feel human and persistent pain reduces the sufferer’s options to interact with others and the world around them.

Graded exposure to physical activity encourages the brain and nervous systems to change our expectations about future movement. Learning to move without fear of harm and knowing that any slight symptoms are not dangerous teaches our pain systems to re-calibrate again. This takes a little bit of time, and plenty of practice, but we now know that the nervous system is highly adaptable and capable of developing new connections as well as forgetting old ones no matter how long we have been in pain. Pacing yourself on this journey is really important and, along with our guidance, patients learn through trial and error how quickly they are able to progress exercise intensity and frequency again.

How deeper emotions affect pain

We are understanding more and more just how significant traumatic past events really do shape how we feel now. This includes early childhood development and even before we were born. The nervous system is changing rapidly in children particularly from the last trimester of pregnancy to the age of 3 years. It picks up on dangerous and stressful events such as abuse or emotional neglect and learns to strengthen connections that keep the nervous system on high alert. The result is often a ‘fight or flight’ response that is triggered easily, something that can amplify pain signalling. There is good evidence that this can have profound effects on how we process pain through childhood and into adult life and patients are often able to make sense of how they feel in general once they explore these deeper feelings. Through childhood, teenage years and adulthood, modern life also comes with stress which we also know helps to maintain a pain system that is more vigilant and easily activated. Our patients often work with clinical psychologists or psychotherapists, were necessary, to help them learn how to dial down pain that is encouraged by past trauma, big life events or when the stresses of life generally become overwhelming and unmanageable.

Develop healthier daily routines

It turns out that lots of the things we engage in in modern life are not necessarily good for us. For example, dietary habits, alcohol, smoking, exercise habits and sleep quality are all very important factors in how our immune system functions and therefore how we process pain. Looking at all the factors that can influence pain is often an easy way to raise pain thresholds again so that we feel pain only when it is useful rather than it becoming invasive and unhelpful.

Experimentally, we know that even one night of sleep deprivation can create a measurable drop in pain threshold and patients with chronic pain often don’t remember the last time they got a good nights sleep. A well designed study looking at women with chronic migraine (more than 15 headache days a month) showed a significant decrease in migraine frequency and medication use just by engaging in sleep behavioural modification - developing a more structured evening and bedtime routine and better sleep quality. We can help people with chronic sleep problems through a variety of means including CBT. We also help patients to engage in the more healthy aspects of their lives through motivational techniques and life coaching.