There is increasing research which shows that pain is not just physical but psychological as well. However, most professionals are reluctant to talk to their clients about the psychological aspects – but if we’re not talking about it, how can we “fix” someone’s pain?
The most talked about pain model is the fear-avoidance model. This model helps describe how chronic or persistent musculo-skeletal pain is maintained by a person avoiding an activity based on fear of pain.
Negative thoughts or beliefs about pain and/or the consequences can lead to feelings of fear, avoidance of activities and hypervigilance. This leads to the person repeatedly avoiding an activity and overestimating the future pain if they participated in the activity.
This avoidance then further results in physical deconditioning, depression or other mental health illnesses, being signed off from work due to disability and an inability to join in with family or recreational activities.
This cycle of far-avoidance continues the persons pain experience rather than helping them recover. By no longer reinforcing the avoidance behaviours the person is able to break the positive feedback loop and begin recovering.
Well, that all sounds super simple, right?
This model can’t account for every pain or fear scenario and its main critics point out that it is very simplistic. Despite that, it is generally acknowledged as the best model we have to understand how people react positively and negatively to fear.
One of the maintaining factors of this cycle is called “catastrophic thinking”. This is when a persons negative thought about pain can lead to catastrophic thoughts (these tend to be very black and white – i.e. "if I hurt my back further I will not be able to walk") which then further contributes to pain related fear.
Catastrophic thinking is usually broken down into three categories:
· Rumination – this is when you are unable to stop thinking pain related thoughts prior to, during or after an activity (“This activity is really hurting.”)
· Magnification – this is when you tend to magnify the threat of pain (“If I do X then something serious will happen.”)
· Helplessness – this is when you can’t see things getting any better no matter what you do (“It doesn’t matter if I attend physio, the pain will always be there.”)
Catastrophic thinking is often the result of maladaptive beliefs. These can be broken down into:
· Overgeneralization – when you take one specific case and apply it to all
· Mental filter – when you focus mainly on the negative despite positive aspects
· Jumping to conclusions – making an assumption from little or no evidence
· Emotional reasoning – making decisions or judgements based on intuition rather than objective evidence.
So that’s all very interesting, but what can we do about it?
There are psychological approaches such as Cognitive Behavioural Therapy (CBT) or Acceptance and Commitment Therapy (ACT). CBT approach believes that pain is complex and the experience will be depend on factors such as pathophysiology, cognitions and behaviours. ACT uses behaviour change strategies to increase psychological flexibility.
Patient education about the diagnosis and prognosis of your condition has be shown to help prevent distorted or catastrophic views in the first place. This is why I always encourage you to ask as many questions as you like prior to, during or after an appointment. Lots of conditions sound very scary (take herniated discs, for example) but actually aren’t once you start to look at research and recovery rates.
If you are too nervous to ask your doctor yourself, you can always ask for a family member or friend to go with you, and you can even pre-write the questions down. Just a side note - whilst Google can be helpful, PLEASE take everything you read with a pinch of salt until you can consult a professional.
Another strategy is to work with a professional to gradually complete the activity that you are worried will cause you pain. This known as graded exposure. The task is broken down into little steps, which increase your confidence and help disprove your fears about movement as you progress, which in turn can help decrease distorted views or catastrophic thoughts.
Long and short of it - I am not to saying pain is all in your head. Pain is an incredibly complex experience with many factors contributing to it. Pain is not a pleasurable experience and naturally we want to avoid it. Sometimes this avoidance can actually lead to prolonging or worsening of our pain – but if these fears are recognised and addressed it can be beneficial to your recovery.