It is National pain week in Australia at the moment, and to celebrate we wanted to educate everyone and raise awareness on the concept of pain.

As physiotherapists we often get caught up in biomechanical/the way we move to be major driver‘s of someone’s pain. However! Although we still believe it is a huge component, it is not the ONLY component that can drive someone’s pain. We need to consider the psychology of pain. The way a person thinks about their pain can have a huge impact on their rehabilitation.

Let’s see how……

What is pain? Pain is the output of complex calculations by the brain. In the physiotherapy world, pain related thoughts can amplify physical symptoms and therefore affect rehabilitation/recovery.

Chronic pain: Defined as any pain lasting longer than 3 months.

There are 4 aspects of pain that can negatively affect rehabilitation/recovery:

1. Pain related thoughts

People with poor self-efficacy (i.e – reduced motivation and ability/confidence of rehabbing themselves). We see this all the time in the practice, people who have chronic conditions relying too heavily on ‘hands on’ (i.e – massage) treatment and not developing motivational and rehab skills (i.e – exercise). This has been found to significantly affect positive treatment outcomes.

People who catastrophise their pain also have poorer outcomes. We often see people who are much more focused on what they CAN’T do, rather than what they CAN do. They are almost always expecting certain movements or activities to hurt every time, which means they are constantly searching for their pain. These are the people that become fixated on their symptoms, which hinders their ability to rehabilitate. This leads to reduced physical activity and movement which can have a detrimental effect on recovery.

2. Pain related emotions

18% (in private practice) and up to 85% (in pain clinics) of people with chronic pain conditions (i.e – chronic back or neck pain, fibromyalgia etc) also have major depressive and anxiety disorders.

It also known that for the same condition, people with chronic pain experience greater pain intensities than the general population.

We often see clients who come into the practice for ‘reassurance’. How many of you, that are reading this, have visited the physio to gain reassurance that your pain or injury is nothing serious?

3. Pain related sensations

Continuing on from pain related thoughts - If someone thinks that a certain movement or activity will hurt, it is more likely to be painful.

This has been proven in experiments where pain can be manipulated by pairing the painful stimulus with something that is perceived to be dangerous, such as the colour red or a threatening noise (Moseley and Arntz, 2007).

People who constantly talk about their pain can increase their pain – this is because they are drawing attention to the area.

4. Pain related behaviours

A person’s behaviour is influenced by their thoughts, emotions and sensations.

If we sense something painful and believe that every time we do a particular movement, it will result in more pain, we become fearful, ultimately effecting our movement behaviours – this is often known as fear avoidance (i.e – avoiding a particular movement, because we think it will hurt)

An example of this can be a post-acute back injury after bending over and picking something up. That person may be traumatised from that incident and therefore any movements that require bending forward or picking something up are now avoided – this is known as fear avoidance. This can lead to helplessness and low self-worth, such as ‘I cannot do that, that will hurt me, I’m not trying that’ etc. Often this will give people anxiety about movement, and before they have even moved they have exacerbated their pain, just in response to even thinking about it.

We try to make people understand why something like that could have occurred and the things we are going to do different this time to enable them. We should not be avoiding, we should be modifying the movement and gradually exposing.

“It is often far more important to know what type of person has a problem, than to know what type of problem that person has” (Adam Meakins).

For example: Case studies - 2 people were seen with the same diagnosis of non-specific lower back pain with symptoms producing muscle strains of the back, and mild irritability at L5/S1 level:

Client A:
Client A: 30 year old female who injured her back bending down to pick up a basket at home and felt immediate lower back pain. The first thing she said to me was ‘I can’t really do much’. Client A was heavily fixated on the diagnosis and was already avoiding bending over. She wanted to get a scan straight away and in the meantime relied on anti-inflammatories, massage and passive treatments because she felt like ‘everything was painful’, despite not trying. It took Client A, 4 weeks to bend forward and pick a basket up off the floor and be symptom free.

From day 1, Client A catastrophised her pain, showed fear avoidance behaviours, was heavily reliant on passive treatments and the things she couldn’t do (rather than could), perceived every movement to be dangerous and therefore was not motivated or confident in herself that the rehab she completed was going to help. This made her pain perception much worse and her rehab was drawn out.

Client B:
23 year old male who injured his back deadlifting at the gym and felt immediate back pain. Client B took an active approach, agreed that he did not need a scan. Some movements were painful, however understood that he could modify the way he was doing things. Client B was back deadlifting in 1 week without symptoms, with slight modifications to his deadlifts to reduce future aggravations.

From day 1, Client B did not show any fear avoidance behaviours, however understood that he could modify the way he was doing things to keep himself motivated and confident in his ability to ‘move’ and rehabilitate his injury.

Ask yourselves these questions:

  • How confident are you to place your rehabilitation in your own hands? How do you think you can get better?
  • Are you traumatised by a particular movement/activity
  • Are you using fear avoidance behaviours?
  • Are you struggling with emotions such as anxiety and depression?
  • How well do you sleep?

We need sleep for recovery and lack of sleep has been correlated with feelings of anxiety and depression.