Chronic pain

Being stiff or weak directly influences how much activity we do, by making it harder to be active. Having weak muscles and stiff joints will increase pain. However, this is also two-way, as pain can directly inhibit muscle activity.

When starting or progressing an exercise, you are likely to feel normal aches/pains due to exercise, which are not associated with harm. Doing any physical activity is better than doing none.

The pain cycle involves a continuous cycle of pain with 3 main elements contributing to each other, including:

• persistent pain: over-sensitised pain system
• altered activity: doing less due to pain
• physical changes: developing weaker muscles and reduced fitness

Usually, when you are in pain or having a ‘bad day’, activity levels reduce. Conversely, when you are having less pain or a ‘good day’, activity levels increase (catching up). However, increased activity on better days can often flare up pain, leading to decreased activity the next day.

This way of managing our activity levels reinforces the link between activity and pain, leading us to avoid more and more in an attempt to get control over the pain.

In general, we see that the overactive or underactive cycle leads to a gradual decline in activity levels. Therefore, trying to avoid these peaks and troughs is likely to be helpful. This is called pacing.

Pacing means balancing activity so that the day is divided into periods of relative rest and activity. It can gradually build on what you can presently comfortably achieve, limit overactivity and help you manage the day better by keeping to your planned target.

Pacing also means doing the activity, whether feeling good or bad, not doing too much or too little. The aim is to maintain an even level of activity over the day and week.

On a good day, you should not wait for the pain to tell you when to stop, but instead you should stick carefully to your plan and avoid overdoing things. On a bad day, you should still try to keep going as planned, but you could break up activities more to make it more manageable.

Example: Cleaning the car

• Prioritise – What must be immediate and what can wait until another time? Dust inside the car and clear out the rubbish because you are giving someone a lift later.
• Plan – Plan activities and think about what order to do things in. Try hoovering the back of the car one day and the front another day.
• Tolerance level – Work out your baseline for each activity to try and find the middle ground between what you would do on a good day and what you would do on a bad day.
• Evaluate – Stick to the plan and re-evaluate after several days. If no problems with dusting and emptying the car of rubbish, next time try hoovering the back seats as well and see how it feels.

Whatever activity you are planning, it is important to work out where to start.

For example, walking:

• Choose the best time of day to walk and select a good place to start.
• Walk at your own pace for a sensible period that you feel you can manage.
• Record the time or distance walked, for example, 15 minutes.
• Repeat again another day and record the time or distance, for example, 20 minutes.
• Repeat again on a third day and record the time or distance, for example, 10 minutes.
• Your baseline should be slightly below your average (approximately 80%, so multiply by 0.8).
• Calculate the average (add scores together and divide by three) for example, 15 minutes.

You can find your baseline by:

1. choosing the activity you want your baseline for

2. completing your activity and recording the amount of time or distance that you can do the activity for

3. doing the same activity again the next day and on the third day

4. calculating your average

This is called ‘graded activity’ and represents an incremental approach to allow physical conditioning to occur. If we have an increase in pain after making a graded increase, we should go back to previous level for a little while longer, or drop down even further, so the increase isn’t quite as much.

Goal setting

A goal should be:

• achievable
• in a set timescale
• written down
• meaningful
• realistic
• broken down into small achievable steps
• rewarded when achieved

If you don’t achieve your goal, learn from this, break the goal down into smaller steps and measure your baseline again. 

Specific – “being able to walk to the local post office and back”

Measurable – be able to monitor progress

Applicable – something you want to do and will improve your quality of life

Rewarding – this will help with motivation

Timed – ‘when’ is it expected the goals will be achieved (short and long term)

When we are faced with a task or a situation, it is the thoughts we have about the task that produce emotions or feelings, which determine how we act.

The unhelpful thoughts cycle involves:

• Thoughts - creating feelings
• Feelings - creating behaviours
• Behaviours - reinforcing thoughts

This depends upon our own previous experiences or what we have learned from others.

Unhelpful thoughts impact our actions and outputs/behaviours. Challenging these thoughts can help to change our approach to activities.

Unhelpful thoughts and feelings can influence all parts of the ongoing pain cycle. Persistent pain, altered activity and physical changes to the body can all contribute to unhelpful thoughts, and unhelpful thoughts can also trigger the pain cycle. 

When we’re in pain, we tense up. Tense muscles, in turn, can become uncomfortable or painful. Relaxation techniques help us to relax these muscles, as well as counteract the side effects of stress. Relaxation can help reduce chronic pain, anxiety, high blood pressure and cholesterol levels.

The best relaxation techniques are those that can be done anytime, anywhere and in any position.

Example: If you were stuck in traffic and could feel your muscles tensing, then you would need to be able to start relaxation techniques while sitting.

The key to succeeding with relaxation techniques is to practice them initially when pain is at a tolerable level, so that when the pain is worse, you know the routine and the techniques can be more effective. 

Lots of different things can impact how much pain you feel.

Example: Have you ever noticed that we sometimes seem to notice a clock ticking more loudly? The ticking hasn’t got louder or quieter, even though it seems louder or quieter.

This is similar to being more aware of your pain at night when it's quiet, dark, and there is nothing much else to think about. The ticking also gets louder when we are worried about the time, which would also relate to pain if you are worried about it. Actions reinforce the thoughts that cause the vicious cycle. We can break this cycle through things like distraction.

Flare-ups are expected as this is the nature of persistent pain. The trick is to have plans for managing the good and the bad spells. 

An effective plan for a good spell:

• progress exercises and goals
• add new goals
• reduce medications
• enjoy yourself
• plan ahead
• stay active
• practice relaxation

An effective plan for a bad spell or flare-up:

• carry on
• review baseline
• review medication
• set goals
• relaxation
• allow personal time
• if possible, identify triggers, learn from them and plan for the next time. However, often there is no clear cause