In issue 73 of Pain Matters, we published an article about the Matrix programme, developed by the Pain Management Centre at University College London Hospitals to help introduce mindfulness into their neuropathic pain treatment.
You can read all about the programme here: thriveglobal.com/stories/how-a-mindfulness-based-approach-is-helping-people-manage-chronic-pain/
Or, to read the original article in our Pain Matters Neuropathic Pain Special, click here to buy or subscribe.
According to the most recent Scottish Diabetes Survey in 2018, there are an estimated 304,000 people living with a diagnosis of diabetes in Scotland, around 5% of the population. A long-term effect of diabetes can be the development of diabetic neuropathy. This edition of Airing Pain focuses on neuropathic pain in people with diabetes, and how the X-PERT diabetes courses helps people to deal with the complications that arise when living with diabetes.
Watch the trailer above for more details
Contributors:
Available to listen on our website, or download from wherever you get your podcasts.
We all know that what we eat can affect our health. New research, however, shows that there may be a specific link between diet and pain. Pain specialist Dr Rae Frances Bell tells us more, and outlines steps you can take to improve your diet as part of your pain management regime
It’s very important for people with chronic pain to maintain a healthy, balanced diet. There are several reasons for this. Firstly, the nervous system has the capacity to dampen pain. Most people have heard of the body’s own morphine-like substances called endorphins. In order to be able to function optimally, the nervous system requires specific nutrients such as essential amino acids. One example is tryptophan, which is a building block in the synthesis of the neurotransmitter serotonin which is very important in the body’s own pain-dampening systems. Foodstuffs such as nuts/seeds, fish, eggs, beans, oats, chicken and turkey contain high levels of tryptophan.
On the most basic level, the nervous system needs nutrients. Certain vitamin deficiencies can cause pain problems. For example, vitamin B12 deficiency can cause very unpleasant peripheral polyneuropathy, which is nerve pain in both feet and also sometimes in the hands. Vitamin D deficiency can cause musculoskeletal pain, as can vitamin C deficiency.
Omega-3 and Omega-6
The World Health Organisation published a report in 2003 which described how there has been a global shift in diet resulting from different factors such as industrialisation and market globalisation. Our diet has changed from being predominantly plant-based to more high-energy density and processed foods, including a substantial increase in the intake of saturated fats and sugars. One factor the report focused on was the balance between dietary intake of omega-6 fatty acids and omega-3 fatty acids. The ‘ideal’ ratio between these fatty acids is thought to be 1:1, while ratios under 5:1 have been associated with reduced risk for heart disease, cancer and auto-immune inflammatory conditions.
However, in the average American diet today, the intake of omega-6 is around 15 to 25 times the intake of omega-3. Foods containing relatively high levels of omega-3 are cold water oily fish such as mackerel, herring and salmon, fish oil, flax seed and flax seed oil; while omega-6 is plentiful in poultry, and in many vegetable oils, especially soybean oil. Soybean oil is used in the production of fast food and snacks and I think this widespread use has particularly contributed to high levels of omega-6 in our diet.
Omega-6 has been linked to inflammation, which is something we need to aid healing in our body. But an exaggerated inflammatory response creates its own problems. Omega-3 has anti-inflammatory effects. Research has found that increased dietary intake of omega-3 reduces joint pain, morning stiffness, number of painful joints and consumption of non-steroidal anti-inflammatory drugs in patients with rheumatoid arthritis. The balance between these fatty acids in our diet is thought to be important. So one thing for pain patients to pay attention to with regard to diet is to ensure they have a sufficient intake of omega-3 while avoiding excessive intake of omega-6.
A number of foods contain substances which have anti-inflammatory properties, just like non-steroidal anti-inflammatory drugs. For example, in virgin olive oil, there’s a compound called oleocanthal, which has been shown to have anti-inflammatory and pain relieving effects similar to ibuprofen. This is really interesting because non-steroidal anti-inflammatory drugs can have a lot of side effects. If we can achieve some anti-inflammatory and pain-relieving effects through eating healthily that would be ideal.
Antioxidants
Antioxidants have anti-inflammatory effects and are found in many foodstuffs. Resveratrol is an antioxidant which is formed in certain plants when they’re under attack by bacteria or insects. It’s found in the skin of red grapes, and in red wine and grape juice, and it has powerful anti-inflammatory and neuroprotective effects. Antioxidants called anthocyanins are found in the reddish-blue pigments in blueberry skins and cherries and in animal studies have been shown to reduce inflammatory pain.
Unfortunately there is a lot of hype in the media about antioxidants, with multiple advertisements telling us to buy antioxidant products. You actually don’t need a huge intake and the best way to get antioxidants is through your diet, not through pills.
I think most people know whether their diet is healthy or not. If we’re busy and just snacking instead of eating regular meals, it’s not good enough. We need to be getting vitamins; we need to be eating more fish, less red meat and lots of fresh vegetables, especially green leafy and brightly coloured vegetables. It’s the colour pigments which contain the antioxidants, so if you think of a colourful, Mediterranean kind of diet then you’re on the right track.
Foods to limit
Some foodstuffs can increase pain. Professor Guy Simonnet and colleagues in Bordeaux have done interesting scientific research on polyamines. Polyamines are important for cell growth and we obtain most of our polyamines through the diet. Polyamines upregulate activity in a receptor in the nervous system which is involved in amplifying pain and a polyamine deficient diet has been shown in a rat study to reduce pain hypersensitivity. Oranges and orange juice contain very high levels of polyamines. That doesn’t mean you should stop drinking orange juice, it just means you should probably think twice before drinking large quantities on a daily basis. Peanuts and potato crisps also contain high levels of polyamines.
Some pain-relieving medications contain caffeine because it interacts with analgesic drugs and can increase the effect of paracetamol and aspirin. But caffeine has other attributes that are actually harmful and regular moderate to high intake of coffee or other drinks containing caffeine can cause problems. Caffeine blocks the effects of the body’s own relaxatory neurotransmitter adenosine. Everyone knows that coffee can disturb sleep. If you have chronic pain and sleep poorly, you will feel more pain. If coffee is consumed on a regular basis, it can also increase the risk of developing a chronic daily headache.
High levels of caffeine are linked to osteoporosis, so if you drink more than four cups of coffee a day your risk of developing osteoporosis increases. This is also the case for other caffeinated beverages such as cola and “energy” drinks. In addition to flavouring, sugar or sugar replacement and water, cola contains phosphoric acid and caffeine. The taste might be nice, but there is nothing else positive about cola. A regular high intake of cola or “energy” beverages can cause sleep problems and increase the risk of osteoporosis in the same way as coffee due to the high caffeine levels.
What to eat
At our pain clinic we regularly ask our patients what they eat. We started doing this more than 20 years ago and quickly discovered that many of them had a poor or sub-optimal diet. There can be different reasons for this – some pain patients suffer depression and have reduced appetite, or they simply don’t feel up to preparing meals. Most are unaware that diet plays a role in pain and that it is especially important for chronic pain patients to have a healthy, balanced diet. By bearing in mind some of these simple principles you may find ways to make the food you eat an important part of your pain management plan:
For dietary advice specific to your needs we recommend you consult your GP, pain specialist or a qualified dietitian. For more information visit bda.uk.com/publications/index.html.
Dr Rae Frances Bell is Head of Multidisciplinary Clinic, Haukland University Hospital, Bergen, Norway.
Dr Bell also discussed this issue in Airing Pain 4: Diet, CBT and Mindfulness.
If you would like to know more about the sources of evidence consulted for this publication please click here.
Diet and Pain © Rae Frances Bell. All rights reserved. Revised March 2019. To be reviewed March 2022. First published August 2013.
Please note: This leaflet is the process of being updated. The revised version will be uploaded in due course.
Most of us will have painful feet from time to time, but it’s usually possible to take care of minor foot problems by making simple changes. Podiatrist and University Lecturer Gordon Hendry gives guidance on looking after your feet and explains when and how to get help for foot pain
Why do people get foot pain?
All kinds of reasons. Risk factors for foot pain include obesity, certain types of foot posture, getting older and sports injuries. People with diabetes can develop neuropathic pain in their feet, and people with vascular problems can develop cramps. The big one we can all do something about is poor footwear.
What should I look for when buying shoes?
High heels and narrow pointy toes are the obvious shoe design features that are hard on our feet, but there are other things besides worth bearing in mind. Our Shoe Shopping Tips can help you make a foot-friendly choice.
Is it better to rest my feet if I have long term pain?
While it’s tempting to rest sore feet, it’s important to keep active for wider health benefits. The strength, flexibility and coordination of your feet and ankles is like anything else – if you don’t use it, you’re going to lose it!
Getting active not only makes you fitter and stronger, but will help to improve proprioception – your sense of where your joints are positioned and how they’re moving. This joint position sense helps you move more efficiently. Poor proprioception has been linked to osteoarthritis which causes pain and mobility problems.
How can I be active when my feet hurt?
If your feet are sore, activity needs a bit more thought than just running on a treadmill. It’s important not to make rapid changes in activity levels to avoid risking injury. Speak to your GP, physiotherapist or podiatrist if you’re unsure.
When should I seek professional help?
If there’s an obvious issue you think might be causing your feet to hurt (such as walking a long way in ill-fitting shoes), try adjusting that yourself. A lot of foot pain can be, and is, successfully self-managed.
However, you should go to your GP for a referral or go direct to a podiatrist when:
If any of the above apply to you, it’s better to get help sooner rather than later. That way you’ll reduce the loss of fitness that comes with inactivity and make it less likely that your pain will affect your state of mind or social life.
What can a podiatrist do to help my foot pain?
A podiatrist will usually be able to diagnose the cause of your foot pain and offer a treatment plan. Podiatrists have specialist knowledge with managing pain related to musculoskeletal problems, where abnormal mechanics in the foot lead to tissue damage and pain.
If your foot pain is caused by nerve damage related to diabetes or problems with blood flow, you may be advised to see other healthcare professionals who can help you manage those underlying conditions.
Orthoses and more…
Orthoses are specially-designed insoles that reduce unwanted movement and change the way forces (such as the impact of your foot on the pavement) are distributed. For example, an orthotic for heel pain might be designed to increase the contact the rest of your foot has with the ground to reduce the stresses on your heel specifically.
Podiatrists can also recommend exercise programmes to enhance the stability and strength of your feet and legs and give guidance on general foot care.
Good foot hygiene includes:
Dr Gordon Hendry is Lecturer in Musculoskeletal Rehabilitation at Glasgow Caledonian University.
If you would like to know more about the sources of evidence consulted for this publication, please click here.
Foot pain – how to manage and prevent it © Gordon Hendry. All rights reserved. March 2016. To be reviewed March 2019.
Further resources:
Breast cancer is the most common cancer affecting women, and surgery – either to the breast and/or the underarm area – is the main treatment. There are two main types of breast operation: a mastectomy (removal of the whole breast) or a lumpectomy (removal of the cancerous lump) which is a breast-conserving surgery. The lymph nodes in the armpit can also be affected and it is common for women to also have a procedure for partial or complete removal of lymph nodes
How common is pain after surgery?
One of the first UK studies of chronic pain after mastectomy was conducted in Scotland in 1999. Over 400 women were surveyed at three years after their breast cancer surgery and 43 per cent still reported pain in the chest and upper arm. Many women reported problems with everyday activities, such as lifting bags, turning the steering wheel when driving and doing household tasks. For some women, the painful symptoms had started fairly soon after their operation; for others, symptoms had started later, possibly relating to radiotherapy and chemotherapy treatments.
Six years later, the same women reporting painful symptoms were resurveyed to find out whether they had recovered. About half of the women with pain at three years were, by then, pain-free; the other half still had pain (on average seven to nine years after their mastectomy). Of those still with pain, the women reported that they had ‘learned to live’ with their painful symptoms – many had tried alternative therapies.
The researchers then conducted another study across Scotland to understand more about the type of pain experienced both before and after breast cancer surgery. They assessed another 400 women before their breast cancer operation and very few reported chronic pain in the breast and upper body. After surgery, over half of the women reported moderate- to severe-intensity acute pain in the first week after surgery. Based on the ‘before’ findings, this pain was not a continuation of any existing pain. The researchers found that, of the 400 women surveyed, those who had more severe acute pain after surgery were more likely to have chronic pain at four and nine months after their operation. This suggests that if healthcare professionals could better control and treat pain immediately after the operation, they may reduce the proportion of women going on to suffer with chronic painful symptoms.
Nerve and phantom pains
Women with neuropathic pain (nerve pain) use terms such as ‘stabbing’, ‘burning’, ‘tingling’, ‘shooting pain’ or ’numbness’ to describe their symptoms. Surgeons may have to dissect branches of the main nerve running through the underarm when removing the tumour and surrounding tissue – this is unavoidable, but may be partly responsible for some symptoms.
Although neuropathic pain is the most common type of pain reported after breast cancer surgery, some women also experience phantom breast pain. Phantom pain is pain that seems to come from an amputated limb, breast or other body part. Phantom sensations after mastectomy might not involve pain, but there are reports of 17 per cent of women up to six years after surgery having phantom breast pain.
What are the risk factors?
Certain groups of women may be more at risk from chronic pain after their breast surgery than others.
Firstly, younger women do seem to be at greater risk of chronic pain than older women – this has been found after many different operations. This finding might be partly explained by the fact that younger people are often more active and are working, thus having persistent pain could have a greater impact on their daily life compared to older people who are perhaps less active. Or it may relate to nerve and tissue changes (how the body reacts to pain) as we get older.
There is recent evidence to show that women with other chronic pains are at greater risk of having chronic pain after their breast cancer surgery. This may include people who suffer from such conditions as chronic low back pain, irritable bowel syndrome, migraine, fibromyalgia and perhaps several other conditions as well. Changes in the nervous system may well lie behind many of these conditions. The field of pain genetics has also suggested that some people may be more susceptible to pain conditions than others.
It is entirely expected that women will be worried and fearful of their future when faced with a cancer diagnosis and impending surgery. Women who are very anxious and worried about their operation are at higher risk of both acute and chronic pain after surgery – so excessive worry and anxiety is a risk factor. This has been found with other operations, not just breast cancer surgery. It is important that support and information are offered to patients to help manage these feelings.
Preoperative preparation is vital; for example, a clear explanation about the operation and recovery process setting out the risks (and benefits) should be undertaken as standard practice.
Finally, one of the strongest and most consistent risk factors for chronic pain after surgery is the severity of acute pain in the days and weeks after an operation. Treatment and adequate control of acute pain immediately after surgery is very important and may ‘dampen’ the pain response, preventing longer term symptoms. Again, there is emerging evidence to suggest that women reporting pain with neuropathic characteristics (such as stabbing, tingling and numbness) in the early period after surgery may be at greater risk of having these symptoms persist in the longer term.
Treatment
Long-term pain after breast cancer surgery is treated in much the same way as other postsurgical pain. Some pain-relieving drugs may not be suitable if women are taking long-term hormone treatment. Refer to the leaflet ‘Chronic Pain after Surgery’ for more details.
Better understanding
An earlier version of ‘Chronic Pain after Surgery’ reported widespread misdiagnosis of pain after breast surgery. There are now many hundreds of articles from around the world reporting that painful symptoms after breast cancer surgery are common, disabling and can be challenging to treat. More is known about the types of surgery that may increase the risk of post-operative chronic pain e.g. surgery to remove all the lymph nodes under the arm (axilla).
Research studies now include larger numbers of patients than the early surveys. One of the largest studies ever conducted was undertaken in Denmark, where almost every breast cancer surgery patient in the country was followed-up two years after their operation. The research team found that out of over 3200 women, half still had pain in more than one area related to their operation, and 58 per cent reported sensory disturbances, such as numbness or sensitivity to touch. Overall 25 per cent of women had moderate to severe pain two years after their surgery. The study also revealed that many women suffering symptoms were under-treated and had poor pain relief and symptom control. This was a hugely important study and was published in the Journal of the American Medical Association (JAMA), one of the highest ranking medical journals. This publication has helped to increase recognition and raise awareness of the condition amongst doctors and healthcare professionals.
Professor Bruce is based at the Warwick Clinical Trials Unit, University of Warwick.
If you would like to know more about the sources of evidence consulted for this publication, please click here.
Chronic Pain after Breast Cancer Surgery © Julie Bruce. All rights reserved. Revised June 2019. To be reviewed June 2022. First published June 2015.
It is unfortunately not uncommon for people in pain to be told by others (family, colleagues or healthcare professionals) that their pain must be ‘all in the mind’. Amanda C de C Williams gives some tips on how you can respond
There is a way of thinking that says that if something cannot be explained medically or identified by medical tests then it must be ‘psychological’. The idea is either that the person ‘believes’ that they have pain, but doesn’t really, or that whatever pain they have arises entirely from mental processes and is not ‘real’. It is different from acknowledging that pain and emotional distress or psychological disorders may be related.
The fact that current medical knowledge cannot explain something does not mean that a mechanism for the pain will not eventually be discovered leading to effective treatments.
If you have been told that your pain is all in the mind, here are four assertive responses you could use:
‘Pain is a mind-body problem. The two can’t be separated.’
‘I’m distressed because of my pain and the problems it causes. Pain causes distress, not the other way round.’
‘I realise it is good news that the investigations [X-ray, scan, blood tests] show nothing serious. But I feel pain because that’s what my nervous system tells my brain and no investigation can show that.’ After all, plenty of acute pains accepted as ‘real’ wouldn’t show up on investigations like that, from headache to muscle cramp to renal colic.
‘If you had pain like this, and it affected your life like it affects mine, don’t you think you would be worried/distressed/depressed/frustrated?’
Amanda C de C Williams is a Reader in Clinical Health Psychology at University College London, and Consultant Clinical Psychologist at the Pain Management Centre of the National Hospital for Neurology & Neurosurgery, London.
Not all in the mind © Amanda C de C Williams. All rights reserved. March 2014.
Persistent pain can impact on mood and on many areas of life such as work, exercise and socialising. This leaflet is designed to give advice to people who have found it more difficult or have had to give up sexual activity because of pain
It is often a difficult topic for people to communicate about and health care professionals may not always feel skilled and confident in addressing sexual difficulties. Those not in a relationship may lose confidence and assume that a romantic relationship is now out of the question. Existing relationships can suffer, particularly if maintaining intimacy is challenging. Studies show that individuals with chronic pain are more likely to experience difficulties with sex than those without pain, and to be anxious about sexual activity.
Myths about sex
Lots of ‘ideals’ or myths about sexual activity are constantly promoted by the media (newspapers, magazines, TV, films etc.). It is really difficult not to take these ideals on board and you may hold them as a standard which your sex lives should live up to. Sometimes having these ideas in your head can make maintaining an active sex life alongside chronic pain even more challenging than it would be anyway. Some commonly held myths are:
It is easy to see how these ideas add to the pressure which you all feel, to have a ‘perfect’ sex life. If you are finding sex painful, then these myths of how sex ‘should’ be can lead you to feel that it is not even worth trying, as you are so far from this ‘ideal’.
Bad experiences with pain
Over time, unpleasant sensations before or during sex, or a flare-up of pain afterwards, may mean that, as with any other activity, you reduce how often you do it, or avoid it altogether. If you continue to be sexually active, this may be because of worry about your partner missing out, rather than because you are enjoying it. The social myths about sex mean that you may not talk to anyone else about this lack of sex, including your partner, and this can feel very isolating. Despite the fact that not all couples are sexually active and that these difficulties are very common in pain, you may feel that you are the only person who is struggling with this. Keeping quiet about it may mean that you don’t realise that in fact your experiences are very normal.
Building up gradually
When sex becomes painful, you tend to avoid it when you can, only approaching it when you feel that you ‘should’ or when your partner wants to be intimate. This leads to an ‘all-or-nothing’ pattern of sexual activity, for example having no sexual contact for a couple of months and then having penetrative sex followed by a severe flare-up of pain. This ‘all or nothing’ pattern doesn’t usually work well for someone with persistent pain. A more helpful approach is to have regular sexual contact, which doesn’t necessarily involve penetrative sex. As well as helping your body to get used to sexual activity in a way which does not trigger a flare-up, it reduces your anxiety and helps you to stay intimate with your partner rather than avoiding any physical contact. There is a well-established graded approach to building up sexual contact known as ‘Sensate Focus’ which works well in reducing your anxiety as well as minimising the risk of flare-ups. This ‘step-by-step’ approach involves taking your sexual relationship back to a level where you feel your pain is manageable, staying at this step for a while (for example, a few weeks), and then moving up to the next level.
Desensitisation
Many persistent pain conditions have elements of ‘hypersensitivity’. That means that sensations which should normally be pleasant and normal, such as touch and stretch, can feel painful. We now have studies explaining that this can be because of changes in your nervous system and not necessarily because you are causing any harm. The good news is that the nervous system is capable of changing the response and the technique used is called ‘desensitisation’. For this technique to be effective, it is important to feel reassured that some temporary increases in pain do not mean that it is harmful. It is possible for a lot of people to gradually build up their tolerance by exploring self-touch regularly. The desensitisation process can be compared to going to a pebbled beach and being in pain the first time you run across the beach but gradually, as you do it more frequently, the soles of your feet get used to it – they ‘desensitise’. Once confidence grows in self-touch, a partner can be involved as long as there is clear communication about what, how long and where touch, stretch and intimacy can be tolerated. For this purpose, Sensate Focus techniques can be useful as a step-by-step approach to introducing intimacy without the pressure of achieving full penetrative intercourse.
Medication side-effects
Medications for pain are sometimes associated with unwanted side effects that can affect sexual desire and performance. You can discuss this with your GP or pain specialist if this is a concern. Sometimes people use medication to manage temporary increases in their usual persistent pain, often known as ‘breakthrough’ medication. It can be useful to take breakthrough medication prior to sexual activity if a flare-up of pain is likely afterwards, though you must take it as prescribed. Developing non-medical strategies for these flare-ups can be very helpful.
Communication
As with any activity involving someone else, you need to communicate to get what works best for you both. This can feel difficult whether you are in an established relationship or with a new partner. It can feel particularly difficult if you ‘buy into’ the myth that sex should always be spontaneous and so never needs to be discussed. To help with communicating about sex, you may want to rehearse what you are going to say, and in the case of a new partner, when you are going to say it. Emphasising how much you want to be close to them, and that you want to avoid your pain getting in the way, will reassure your partner that you are not using your pain as an ‘excuse’ to avoid sex. If it feels difficult to talk, you could consider showing your partner this leaflet to read, as a starting point for a conversation. It is difficult to communicate about what you would like without knowing it yourself, so you may want to start the desensitisation or sensate focus steps described above on your own, so that you know what you can do without triggering a severe flare-up of pain. You can then involve your partner at a later stage.
Prioritising sex
Like any activity which you want to do regularly, you need to prioritise sexual activity so that it becomes a normal and an enjoyable part of your life. It is very easy for it to get ‘lost’ in all the other pressures of day-to-day life, whether you have persistent pain or not. You also need to prioritise the elements of your romantic relationship which will help you to stay close, such as being affectionate and spending time together. Sometimes these elements can suffer when sex is difficult, as there is a worry that any physical affection will lead to sex, which will be painful. Communicating about this so that you can continue to be affectionate often makes a big difference to how close you feel to a partner.
Before sex
Remember that pain can be ‘wound up’ by several factors including activity, mood, environment and biological changes. Some of these factors may be possible to change and some not. Self-management approaches can be helpful here. There may be strategies you can use to manage the pain prior to intimacy, particularly those that help you feel relaxed. You may wish to involve your partner in these strategies such as having a bath or shower together, having a massage or listening to relaxing music.
Managing flare-ups
Flare-ups of pain are a normal part of living with persistent pain, and if they happen after sex it is best to have a plan for how to manage them, as this reduces your anxiety about them. Ideally you also communicate this to your partner so that they understand what you are doing. A flare-up plan for pain may involve, for example, having a hot bath, taking pain medication, using an ice pack, doing some stretches, and reminding yourself that the flare-up will pass.
Self-help resources:
Sarah Edwards (Clinical Psychologist), Katrine Petersen (Physiotherapist in Pain Management), Katie Herron (Clinical Psychologist) are part of the multidisciplinary team at the Pain Management Centre at University College London Hospital.
They deliver self-management support to people with abdomino-pelvic pain (APP) via group programmes and individual sessions. Their work frequently involves supporting people with persistent pain with improving sexual activity and managing relationships, using approaches drawn from established pain management research and sex therapies. Following several years of experience, the authors have presented and published their clinical work internationally to encourage clinicians to facilitate open discussions and offer therapeutic interventions on sexual activity in the context of persistent pain to their patients.
If you would like to know more about the sources of evidence consulted for this publication please click here.
Sex and Chronic Pain © Sarah Edwards, Katrine Peterson & Katie Herron. All rights reserved. Revised March 2019. To be reviewed March 2022. First published November 2017.
People living with long-term pain may be offered treatment with a TENS machine to help ease their symptoms, but what is it? How does it work? And what can it bring to your pain management toolkit? Physiotherapist Dr Pete Gladwell draws upon his clinical experience and research to answer these questions and explain the effects and benefits of TENS
How does TENS work?
TENS stands for transcutaneous electrical nerve stimulation. TENS devices have been around since the 1960s and help in pain management by delivering electrical impulses across the skin.
TENS machines are usually a small box with wires leading to self-adhesive pads, although wearable belts suitable for back pain are also available. The pads are placed on either side of, on top of or close to the painful area. When switched on you get a tingling sensation under the pads. My usual advice is to aim for a strong, but comfortable, sensation. The right sensation for you can be found using the controls on the TENS machine.
The TENS machine works through different mechanisms. Some research shows that the TENS machine operates through the pain-gate, a special system that helps to block pain messages going up through the spinal cord. Other evidence suggest that the TENS machine also stimulates some of the opioid systems, or natural pain-killing systems, within the body. The third mechanism, which my research suggests as well, is the distraction mechanism; it may actually just take your mind off the pain.
Can TENS be useful to everyone?
For some people, using a TENS machine leads to pain relief. For others, the sensation just takes their mind off the pain for a while.
Unfortunately, for some people it is not helpful or they find the sensation too unpleasant. In our clinics we encourage people to change the sensation to suit them, but it may not work as people’s experience of pain is diverse.
People should NOT use TENS if they have epilepsy, a heart rhythm disorder, a pacemaker fitted or if they are pregnant (except for pain relief during labour). If you are unsure, speak to your healthcare professional.
As far as we can tell, the TENS machine can be used for all pain conditions, providing there is no health reason preventing its use. However, it can be difficult if you have many pain sites especially if the pain can move and vary throughout the day, so you end up chasing after the pain with the TENS machine.
People with widespread pain such as fibromyalgia syndrome may feel that it is difficult to choose a specific area to treat, but it may be possible to select one treatment area such as the lower back, to see if the TENS machine can offer an overall benefit. There is a randomized controlled trial exploring exactly this approach which is due to report its findings soon. However, people with widespread pain often have a localised pain problem which can be helped through using a TENS machine, even if it doesn’t help their more widespread pain. It is down to each individual to try out different approaches to see what may help them.
Different Strategies
We asked people who had experience of using TENS about the ways that they used their TENS machine, the benefits they got and how they overcame their problems. From this research, there seemed to be five main strategies that people had worked out to gain the most from their TENS machine:
These different methods show how a range of people can find using a TENS machine beneficial by using different strategies.
When it comes to the benefits, some people talk about direct pain relief. However, some people also find the distraction from their pain really quite helpful. This is known as counter-stimulation, where a more pleasant sensation helps you to manage your pain. These people asserted that the distraction was a separate benefit from pain relief, as it can just provide a break. Some people said that using TENS could help them to do more despite not necessarily reducing the amount of pain. Others found that TENS use could help them to fall asleep more easily. These aspects are currently the focus of research on the benefits of TENS machines.
Hints and Tips
More information
Dr Pete Gladwell is Clinical Specialist Physiotherapist in the pain management service at North Bristol NHS Trust in Bristol.
If you would like to know more about the sources of evidence consulted for this publication please click here.
TENS for pain relief © Peter Gladwell. All rights reserved. Revised June 2019. To be reviewed April 2022. First published April 2015.
What is chronic post-surgical pain? How common is it? How is it treated? Professor Julie Bruce & Professor Stephan Schug explain
What is chronic post-surgical pain?
Let’s start with some definitions – acute postoperative pain is the pain experienced immediately after an operation, usually lasting for days or sometimes weeks – this is entirely normal and expected. The surgical incision and surrounding area can be inflamed and tender – again this is fairly normal and is important for wound healing, where tissues and muscles repair themselves after injury.
Chronic pain is normally considered to be pain that persists or keeps coming back for more than three months or for longer than the expected healing time. Chronic pain that develops after an operation is often known as ‘chronic or persistent post-surgical pain’.
Knowing when pain becomes chronic after surgery is especially difficult because many people have had their surgery to treat a painful condition, such as a painful hernia or a long-standing back problem. Is the pain simply a continuation of the old pain, or is it new? And, even if it is new, is it related to the surgery?
Sometimes it is obvious that something has changed – nerve damage after an operation for hernia repair can be quite different from the discomfort felt before the operation. Another example is persistent tingling nerve pain in the chest wall after heart bypass surgery, which is very different from angina pain experienced before heart surgery.
Sometimes it is very difficult to tell the pains apart, especially if the original pain (that the operation was done to treat) was not in fact helped by the surgery. However, these are the features that can allow doctors to tell if you have chronic post-surgical pain:
Surgical follow-up can be limited to one postoperative appointment, thus a follow-up clinic at approximately 8 weeks, to determine surgical ‘success’. Patients are then discharged and managed by the primary care team.
What type of pain is it?
The type of pain can depend on the operation itself, because the painful symptoms often relate to the distribution of nerves in the area of the operation. For example, after groin hernia repair surgery, people have reported pain down the front and inside of the thigh, or in the testicles. This may relate to potential irritation of nerves in the groin during surgical repair of the hernia.
We now understand more about nerve pain or ‘neuropathic pain’ which can arise from nerve injury. Typical characteristics and descriptions of neuropathic pain include stabbing, tingling, numbness, altered sensations and problems with sensitivity. It is not always possible to avoid nerve damage during an operation, especially during cancer surgery when removal of the tumour takes priority.
Treatment of chronic post-surgical pain
Treatment does not depend upon what sort of surgery you have had but rather on the mechanism that results in you having the persistent pain. For example, not everyone who suffers pain following a mastectomy will have the same ‘type’ of pain or for the same underlying reason. The treatment will depend on the characteristics of the pain and also the possible reason for the pain developing and not on the fact that the surgical operation happened to be a mastectomy.
It is important that the healthcare professional listens to your story, performs a thorough examination and allows you to give a full explanation of your symptoms. The healthcare professional then gains an understanding of the problem and the impact the pain has on your daily life. Patients often report finding this approach helpful in itself. Often they feel that, in the past, their symptoms have been dismissed and not taken seriously. Sometimes, people have been told that the pain will go away soon after the operation and this causes mistrust and resentment.
The best treatment for the pain will depend upon the mechanism causing it. Treatments include: tricyclic antidepressants, anticonvulsants, painkillers, TENS (transcutaneous electrical nerve stimulation) and injections. Based on our clinical experience, nerve destruction (peripheral nerve ablation) should not be used in the management of chronic post-surgical pain.
It is not always possible to control the pain and other symptoms adequately. In such cases, a psychology-based pain management approach or physiotherapy support can help you to cope with your symptoms and reduce the impact on your daily life.
How common is it?
A survey asked over 5,000 patients attending pain clinics across Scotland and the north of England carried out in the late 1990s about their reasons for attendance. Twenty per cent of patients thought that surgery was one of the causes of their pain and, of these patients, half thought it was the only cause. Until this report was published, chronic pain after surgery was thought to be rare. This is possibly because few patients were asked about persistent pain after their operation.
On average about 30 per cent of patients experience chronic pain after surgery, although this ranges from those with mild symptoms to those with more severe pain. Overall, only about five per cent of people report severe intensity pain, but five per cent is a significant number when you consider the huge number of operations conducted across the UK and globally.
Are there risk factors?
We are beginning to understand more about risk factors for chronic post-surgical pain. As well as the impact on quality of life for those affected, chronic pain is difficult and costly to treat, so understanding more about who is at risk of developing chronic pain after surgery is important as it may help in preventing the condition.
Certain groups of patients may be more at risk from pain after surgery than others. Women are more likely to experience chronic pain than men, although this is not always the case after surgery. Studies suggest women are more likely to report more severe acute postoperative pain, but the evidence for chronic pain is less certain.
Younger patients do seem to be at greater risk of chronic post-surgical pain than older patients – this has been found after many different operations. This finding might be explained by the fact that younger people are often more active and are working, thus having persistent pain could have a greater impact on their daily life compared to older people who are often less active. Or it may relate to nerve and tissue changes (how we react to pain) as we age.
People with other chronic pains are at greater risk of developing chronic pain after surgery. This may include patients who suffer from such conditions as chronic low back pain, Raynaud’s disease, irritable bowel syndrome, migraine, fibromyalgia and other conditions. Changes in the nervous system may well lie behind many of these conditions. There is growing research on the genetics of pain, suggesting that some patients may be more susceptible to pain conditions than others.
Patients who are more anxious and worried about their operation are at greater risk of acute and chronic postoperative pain – so excessive worry and anxiety is a risk factor. Preoperative preparation is vital; for example, a clear explanation about the operation and recovery process setting out the risks and benefits is an essential part of surgical treatment. Many hospitals run preoperative clinics whereby patients attend for tests in advance of their operation. This is an opportunity for careful explanation and discussion between the patient and health care team.
Finally, one of the strongest and most consistent risk factors for post-surgical pain is the severity of acute postoperative pain in the days and weeks after an operation. Treatment and adequate control of acute pain immediately after surgery is very important and may ‘dampen’ the pain response, preventing longer term symptoms.
More awareness needed
It is clear that chronic post-surgical pain is common, can be severe and may result in distress and disability for patients. Looking at the whole spectrum of chronic pain conditions after surgery, it is very unlikely that the cause of the pain is something that the surgeon has done wrong. It seems more likely that this is the inevitable result of surgery in a certain percentage of patients – approximately 30 per cent of patients experience chronic post-surgical pain of varying severity in the first year after an operation.
If it were more widely accepted that chronic pain can arise after surgery, some patients might decide against having operations that aren’t entirely necessary. Surgeons, who are undoubtedly trying to do the best for their patients, would also be reassured that pain is probably not the result of surgical error. Another benefit is that patients would have their pain acknowledged and would be treated more sympathetically.
Over the last 30 years, there has been a huge increase in medical research investigating the characteristics and potential causes of chronic pain after surgery – this has helped raise awareness amongst healthcare professionals and patients alike. There is still, however, much more work to be done to improve our ability to prevent people from developing chronic pain after surgery and to make sure everyone affected by this all too common condition receives swift diagnosis and treatment.
Finally, let’s look at some examples of different operations…
Pain after hernia surgery
Inguinal (groin) hernia is a common condition with an incidence of six per cent to 12 per cent in adult males. It affects men more often that women. The condition presents as a lump in the groin, due to a protrusion of intestine through a weakness in the abdominal wall in the groin. This lump can affect daily activities and is often, but not always, painful.
Surgery to repair inguinal hernia is one of the most commonly performed operations. Some surgeons use key-hole or laparoscopic surgery rather than an open incision. A mesh is often used to repair the abdominal wall weakness, secured in places either using stiches, glue or staples. There is a small risk that the nerves in the groin can become irritated or inflamed by the implant or internal stiches.
Chronic pain after inguinal repair surgery is now a well-recognised condition – it is one of the most widely reported surgical conditions with hundreds of articles reporting prevalence of up to and around 30 per cent. Approximately 5 to 10 per cent of patients report pain after their hernia operation that interferes with daily living. There is now guidance recommending that it is safe for surgeons to ‘watch and wait’ with some patients who have a small pain-free lump, as long as the hernia doesn’t impact too much on their daily activities.
Pain after chest surgery
When you consider what is involved in surgically opening the chest (thoracotomy), it is not surprising that many patients suffer long-term pain afterwards. In order to gain access to the chest, the surgeon has to either remove part of a rib or spread the ribs apart. This inevitably causes damage to bone and nerves lying along the ribcage.
Experience suggests that many of the worst pain syndromes may be caused by partial nerve injury – thus it may be that a ‘clean’ cut of the nerve has a better long-term outcome, although this can result in numbness and loss of sensation. Although pain after chest surgery is fairly common, the severity of pain varies. In one study, 15 per cent of patients with chronic pain after chest surgery were sufficiently troubled to warrant referral to a pain clinic.
Pain after amputation
Pain after limb amputation is a well-recognised post-surgical pain condition. After limb amputation, the pain can be either stump pain or phantom pain (pain felt in the limb that is no longer there). In stump pain, patients often report a tender spot on the stump and this has led many surgeons to perform further operations to try and find the cause. Patients in the past have frequently had further amputations in the mistaken belief that this would cure the problem. Such operations rarely help stump pain and sometimes make it worse or make it more difficult for the patient to wear an artificial limb.
Phantom limb is a feeling or sensation that the limb is still there, this is normal and does not require treatment. But phantom limb pain (pain in the limb which is no longer there) can affect between 50 to 85 per cent of amputees. It usually starts in the first few weeks after surgery. Studies suggest that painful phantom symptoms can last between one hour and 15 hours a day and can vary between five days a month and 20 days. Pain severity can also be very variable.
It is now acknowledged that children get phantom limb pain and that people born without limbs also suffer from it. Recent research has shown that part of the pain after amputation arises due to activity in the brain itself and this underlines the futility of methods of treatment aimed directly at the stump.
Other chronic post-surgical pain syndromes
Other operations with known risks of chronic pain include vasectomy, joint replacement surgery, spinal surgery for back pain and breast surgery for cancer treatment. Other leaflets in this series discuss strategies for the management of chronic pain.
Professor Bruce is based at the Warwick Clinical Trials Unit, University of Warwick.
Professor Stephan Schug is based at the University of Western Australia, Perth, WA.
This leaflet is an update of a previous leaflet published by Dr Bill Macrae, now retired.
If you would like to know more about the sources of evidence consulted for this publication, please click here.
Chronic Pain after Surgery © Copyright Julie Bruce & Stephan Schug. All rights reserved. Revised June 2019. To be reviewed June 2022. First published June 2015.
How does the law affect people who use drugs to manage their pain?
This edition is funded by Foundation Scotland
On 1 April 2019 Pregabalin and Gabapentin, drugs recommended for the management of neuropathic pain, were re-classified as class C controlled substances.
Medicinal Cannabis: Is it safe? Does it work for pain? Is it legal?
Where do people who use these drugs to manage their chronic pain now stand within UK law?
Issues covered in this programme include: Cannabinoids, cannabis, epilepsy, seizures, drugs, medication, policy, gabapentin, classification, legality, prescription, neuropathic pain, pregabalin, Schedule One drugs and Schedule Two drugs.
Contributors:
How pain’s subjectivity makes it difficult to measure, rewiring the brain and new research that allows patients to visualise their pain
To listen to this programme, please click here.
This edition is funded by the Plum Foundation.
In this edition of Airing Pain, returning contributor Mark Johnson, Director of the Centre for Pain Research at Leeds Beckett University, speaks to Paul about the experimental methods used in their lab to measure how pain is experienced. Professor Johnson emphasises the difficulty in communicating one’s pain, as it is entirely context-driven and based on the experiences of the patient.
Paul then heads to Manchester University to speak to Professor of Neuro-Rheumatology Anthony Jones. Paul learns about the different techniques used to measure the alpha waves produced by the brain when pain occurs, how the anticipation of pain is as important as pain itself and the difficulties that scientists encounter when trying to emulate these signals. We also hear about the brain’s ‘plasticity’ – its ability to rewire connection based on sensory experience.
Anthony’s research team are developing a ‘smart neuro-therapies’ platform (which you can get involved in, see ‘More Information’ below), a way for patients to measure their brain’s alpha waves, which are important in controlling sensory experiences. The research could have significant implications in pain management. The team are employing a unique collaborative theatre piece, Pain, the Brain and a Little Bit of Magic, to help patients, healthcare professionals, and the public to understand these complex systems.
Issues covered in this programme include: Brain imaging, brain signals, communicating pain, electroencephalography, fibromyalgia, neuro-rheumatology, neuro-therapy, neuropathic pain, research, rewire the brain, sleep and trigeminal neuralgia.
Paul Evans: This is Airing Pain, the programme brought to you by Pain Concern, the UK charity that provides information and support for those of us living with pain and for health care professionals. I’m Paul Evans and this edition of Airing Pain has been funded by the Plum Foundation.
Mark Johnson: I’m a pain scientist, I’ve been in the field for well over 20 years. And the longer I’m in the field, the more I become uncertain about how we try to document pain in research settings.
Evans: How do researchers measure something as subjective as pain? On a standard pain rating scale, that is where zero is no pain and ten is extreme pain, someone might rate today’s pain at eight, but a much better, more bearable five the following day. It might be the same level of pain, but the experience of it is different. Mark Johnson is Professor of Pain and Analgesia at Leeds Beckett University. He’s also director of its Centre for Pain Research.
Johnson: One of the things we do in our lab is to use experimental pain techniques that are, in the main, non-injurious. So these are what we would call transient, temporary interventions whereby, for example, we might press a pressure probe on to the skin and keep pressing it until the person says that it’s become painful. And then we measure the pressure that it took for the person to first experience the pain from the pressure probe, and we call that pain threshold. But as soon as you remove the probe, then the person’s pain disappears, pretty much immediately.
Our other techniques involve, for example, plunging a hand into a bucket of icy water, and the person has to keep the hand in the water, tell us when they first feel the experience of pain, which we measure as pain threshold, and then we may well ask them to keep their hand in the bucket as long as they possibly can. And to take it out when they can no longer bear the pain from the ice water. And when they take their hand out, then we measure that time as the time-to-pain tolerance. And of course, when they take their hand out, then the pain starts to disappear quite, quite rapidly, and there’s no lasting damage from that type of technique.
Evans: It’s quite interesting because pain is subjective, and even from a day to day point of view, pain is different. I can remember being asked for years and years ‘Are you in pain?’ and you say ‘No, I’m not in pain, I’m aching’, but aching is pain.
Johnson: Yeah, yeah. Pain is exactly what the person says it is. Pain is subjective. So we’ve got no objective measure of pain. There’s no probe that we can put on somebody that will identify that that person is or is not in pain. So as a consequence, pain is very much about a person’s ability to communicate their sensory experience, the sensations that they’re feeling at that moment in time. For them to do that is really all about when they decide to use particular words to describe those sensations. Whether it’s an ache or a pain is really determined by that person and the context in which the question has been asked.
I’ve always been concerned about scaling pain. Often patients are asked ‘Can you tell me on a scale of one to ten, how much pain you’re in at this moment in time? Where one’s minimal pain and ten’s the worst pain imaginable?’ And that’s actually quite hard to do. I don’t convert my pain into numbers.
Evans: It’s very difficult.
Johnson: Absolutely. And there’s a little bit of an assumption that that scale is linear. Certainly, we know that if you compare somebody’s pain intensity rating of five with somebody else’s pain intensity rating of five, you cannot say that those two people are experiencing the same intensity of pain, because pain is personal to them.
I prefer using scales that are more descriptive. My pain’s moderate, my pain’s severe, my pain’s mild. I think you get a better insight into what the person is experiencing when they’re using those sorts of terms.
And yes, when do you convert an ache into the sensation of pain? Well, again, it’s the context. If you’re in a pain clinic, and you’re trying to explain to a physician, for example, that you’re experiencing something that is really quite distressing, you might use the word pain. But if you’re in a, I don’t know, a social setting, you might just use the word ache. So pain’s very much dependent on the context in which you’re expressing it.
Evans: So what sort of experiments are you doing in here?
Johnson: We’ve got two main themes. We look at factors influencing an individual’s response to a noxious stimuli. We call it pain sensitivity response and that’s things like the age of the person, the gender, the sex of the person, ethnicity, and body fat composition, for example. So that’s one strand that we look at. And another strand is the factors that influence a person’s response to treatments, mostly non-pharmacological treatments. I’m particularly interested in TENS, acupuncture, things like kinesiology taping.
Evans: What sort of results have you found?
Johnson: With respect to the factors influencing individual response to noxious stimuli, painful stimuli, we found that gender role does seem to have an influence. So it’s well-established in the field that the pain threshold of women tends to be lower than the pain threshold of men. And there’s been a debate of whether that’s just that women are more likely to report pain more readily than men, or not.
Animal studies suggest that actually, there’s a biological underpinning to that finding. In our studies, we have found exactly the same, that women express pain more readily than men in laboratory settings and that their pain threshold and pain tolerances are lower than men.
And what’s quite interesting about our work is that we found that that seems to link into what’s called gender role. It’s a societal view and in certain societies, that men need to be tough. For example, they need to be able to withstand pain and situations in which they’re experiencing pain. We’re finding that that sort of plays out in the studies that we’ve been doing in the lab. And that seems to go across culture as well. We do quite a lot of work on people from Arab countries, from the Middle Eastern, North African countries. We found that that gender role seems to play across into those cultural settings as well.
Evans: Some people might be surprised that women’s pain threshold is lower than men. Particularly in the UK, where we have this thing called man flu, just anything will send us to bed in agony, whereas women carry on.
Johnson: Yeah, but as I said earlier, pain’s all context-driven. So I think it’s the context in which you’re expressing how you feel. So in a laboratory setting, the subjects do know that it’s an experiment that will be comparing men against women. So I think there’s a whole load of factors that play out in that setting.
Men will express their man flu more readily, perhaps in a societal setting because they’re wanting sympathy from their wives, their partners, their friendship group. Men tend to not express (I find being a cyclist), those sorts of ailments as much when they’re with their fellow sporting colleagues. Now I’ve got no research to back that up. But I think it’s just that idea that context really drives the way that we express how we feel.
Evans: Men maybe don’t want to show other men that they’re in pain, the alpha male of the group and things like that, I suppose.
Johnson: Yeah, yeah, yeah. I think there have been studies done but they’ve looked at these sorts of settings where you’re doing, say, the cold plunge experiment. When there’s been a female observer and a man participant, and a man observer and a man participant and playing that dynamic out, the investigator’s gender and sex is also quite important, I think.
Evans: Professor Mark Johnson, director of the Centre for Pain Research at Leeds Beckett University.
So there are many variables to take into account when one is measuring pain. Wouldn’t some form of diagnostic readout like we have in the motor industry be very handy?
Anthony Jones is Professor of Neuro-Rheumatology at Manchester University where he leads the Human Pain Research Group.
Anthony Jones: We call all the different ways of trying to get a readout of what the brain is doing ‘functional brain imaging’. So that’s just a collective term for different types of ways of measuring what the brain is doing. There are a number of different techniques. Electroencephalography, which we use a lot, which is recording electrical signals on the surface of the scalp. So this is a non-invasive technique and that’s able to pick up conversations that are going on in the surface of the brain.
Evans: Hang on, now, what do you mean [by] ‘conversations that are going on in the brain?’
Jones: The way that the brain communicates with itself, and different parts of the brain, is through sending electrical signals and receiving electrical signals to different parts. So, if you imagine a huge number of circuits, some very small, some very extensive, all communicating with each other at the same time. Of course, many regions of the brain are doing many different things, and doing some of those things at the same time. So it’s a very complex organ to try to understand.
Evans: So the brain is talking to itself, if you like, or different parts of the brain are talking to itself?
Jones: Yes.
Evans: Is there a point in the brain that is purely involved in pain? Is there a pain centre in the brain?
Jones: Well, that’s a really interesting question and it’s preoccupied neuroscientists for many decades, if not a century, and the conclusion has to be no, there isn’t a single pain centre. In fact, this is one of the pieces of work that we did right at the beginning of my career when we were the first group to use a technique called positron emission tomography, which is a way of measuring blood flow, and other chemical changes in the brain.
Before the advent of functional brain imaging techniques, the only way you could access how the brain might be responding to pain was actually by sticking electrodes or stimulating different bits of the brain during neurosurgical procedures when people have to be conscious, awake, because you need to know whether you’re interfering with functionally essential bits of the brain.
So there’s a number of neurosurgeons, mainly in Canada, who are very painstakingly either stimulating different bits of the surface of the brain, or sometimes recording as well and they had real difficulty eliciting pain at all by stimulating different bits of the surface.
[During the] 50s and 60s there was a great interest in psychosurgery, so chopping out different bits of the brain. So there was a great vogue for people with very serious depression and other psychiatric problems, cutting out, chopping out bits of the frontal cortex (so the front of the brain). That obviously had a fairly major effect on people’s personality and motivation. So they started chopping out or chopping the connections to a bit of the frontal cortex, which is the more emotional bit of the frontal cortex called the cingulate cortex. When they did that patients still felt pain, so they were able to register pain, but it no longer bothered them.
Evans: So you’re taking the emotion away from the pain?
Jones: Exactly. And that was the sort of first indication that perhaps the sensory, so the ‘Where is it?’ and the ‘When is it?’ aspects of pain might be processed separately to the emotional aspects of pain.
Evans: An example that lots of people use is that if you stamp on my foot, and I’ve just won the lottery, I don’t mind the pain, the pain is okay. But if you stamp on my foot and something really bad has happened to me, I really feel the pain.
Jones: Absolutely. The one thing that we’ve learned from three decades of functional brain imaging is that the experience of pain is a highly variable, highly plastic process that is very context-dependent. So we’re really talking about the psychological context, which is what you were just mentioning.
A beautiful example of that is the placebo effect, which is really the ability to experience something completely differently. Not because of anything physical, just because of a verbal or visual cue about what you might be about to experience. This is why we can be hopeful about pain because it’s all processed in the brain. The brain is a very powerful organ and we can actually change the way it’s processed, so there is this plasticity.
When you experience pain, there’s lots of different components to that. There’s the actual stimulus that might be painful, so sticking a needle in the skin or moving a painful joint. But there’s also all the things around that. So there’s the expectation or the anticipation for that stimulus or that experience. There’s also what comes afterwards, so how you respond to that. Is it going to stop you moving or is it going to make you move faster?
We’re built to – or designed to – respond in different ways to pain under different circumstances. So if you’re anticipating pain caused by a nasty animal that might kill you, well, you’re going to have a very different response to that [than] to anticipating pain that might come from a painful joint. You can interrogate that in a laboratory and look at how the brain responds both to the anticipation of pain and to the actual pain itself. What we’ve learned from studying that over the last few years, is that the anticipation of pain is almost as important as the actual stimulus that causes the pain, in terms of informing the experience that we actually have.
Evans: But for those who have chronic pain, permanent pain, there’s no anticipation involved, we know that we’re going to hurt tomorrow. So how does the brain react to that?
Jones: You say there’s no anticipation, but there will always be anticipation because you’re always projecting what you might be experiencing into the future. In fact, a large part of our brain is geared to just planning for the future, particularly the front of the brain, the frontal cortex is very involved in memory. So remembering what happened before, projecting what might be happening in the future and integrating those things into a current experience.
The brain has this job of interpreting actual sensory experiences, but also integrating that with previous experience. It’s juggling the actual sensory input, if you like, the here and now, with what’s happened before, and how that might affect the current experience. So the brain, in that sense, is doing a kind of virtual reality job on how we feel.
In some people, their pain may be more driven by what they’re expecting than the actual sensory input. Other people may be much more driven by just the sensory input and less influenced by what they’re expecting. So what we’ve found in patients with different types of chronic pain, including fibromyalgia and osteoarthritis, is that there’s a fine-tuning problem in the brain in the way they do that integration, such that people with chronic pain are tending to anticipate more. So there’s more processing of that, expectations in certain bits of the brain, particularly in a small island of cortex, called the insular cortex. That increased expectation correlates very nicely with the extent of their symptoms, so how extensive and severe the pain is. Whereas the bits of the brain that are concerned with controlling those responses in the frontal cortex are less active and that correlates very nicely with less good coping strategies. By that, I mean, the tendency to think things are going to be terrible ‘Oh, my God, it’s all going to be ghastly’, so what we call catastrophising.
Evans: So the big question is, you talked about plasticity of the brain, that’s the brain’s ability, if you like, tell me if I’m wrong, to rewire itself. How do you rewire the brain or can you rewire the brain?
Jones: Well, that’s a really good question that we don’t really know the answer to. We know the brain can rewire itself in terms of remaking connections. If the brain is damaged, it can remake connections, although we don’t really understand that process very well. That’s very important to patients who have chronic pain as a result of damage to the brain, such as patients who have post-stroke pain, for instance.
But it can also virtually rewire itself by just changing the strength of those connections in the brain. One very famous example of that is if you look at London taxi drivers. The bit of the brain called the hippocampus, which is concerned with learning about spatial things, such as streets and where streets are, is bigger than normal. If they stop driving taxis or stop learning about driving taxis, then that changes and it goes back towards the normal. So the brain is continuously changing in that way, reinforcing connections for some things, reducing the strength of those connections for other things. That’s what we call plasticity.
Evans: So if we know that we are catastrophising, that the worst is going to happen, ‘I’m going to get up this morning, and it’s going to be absolutely grim’. If you could change the way, or if I could change the way I think about things. I wake up in the morning and the sun is going to be shining and why should I catastrophise in the first place, that might rewire a little bit of my brain to make me feel less pain?
Jones: Yes, and there is some quite good evidence that happens both functionally and structurally. A few years ago, we looked at the effects of a kind of cognitive therapy or talking therapy called mindfulness-based cognitive therapy. We found that if patients just got a short course, so an eight-week course, of this kind of therapy, these fine tuning problems that we’ve discovered in the brain could be partially, not completely, but very substantially improved.
Functionally, we know we can change and those changes, correlated with reductions in the unpleasantness of the pain, but we also know that structurally similar things can occur, and that they can also be reversed. So a number of people, including researchers in Oxford, have found changes in the structure of the brain in relation to the grey and the white matter and that, if the pain improves, then some of those structural changes can be reversed. So again, it’s this idea that although chronic pain is difficult to treat, a lot of the processes that seem to be important in perseverating that pain are actually, or potentially reversible.
Evans: That’s Professor Anthony Jones, who is Professor of Neuro-Rheumatology and leader of the Human Pain Research Group at Manchester University. The group are still looking for volunteers. Volunteers, that is, who have chronic pain, and those who don’t have chronic pain, to take part in their study to develop and test a therapy for chronic pain that increases pain resilience. For more information, just check out their website, which is research.bmh.manchester.ac.uk/pain and look for the drop-down link that says ‘Want to volunteer?’ Now if that’s all too much to remember, just contact Pain Concern and we will put you in touch.
I just need to remind you that whilst we in Pain Concern believe information and opinions on Airing Pain are accurate and sound, based on the best judgements available, you should always consult your health professional on any matter relating to your health and well-being. He or she is the only person who knows you, your circumstances and therefore the appropriate action to take on your behalf. You can download all editions of Airing Pain from Pain Concern’s website, which is painconcern.org.uk, where you will also find a wealth of material and information about living with and managing chronic pain, including our newly developed Navigator Tool to make consultations between you and your doctor much more effective.
Now, creating greater understanding of pain is at the heart of what we do at Pain Concern and bridging a communication gap, perceived or otherwise, between patients and healthcare professionals, is something that more and more doctors and researchers are trying to do. No more ivory towers where, in days of yore (well, hopefully anyway), patient involvement wasn’t seen as part of the medical solution. And, in that spirit, Professor Anthony Jones uses the power of public performance for chronic pain sufferers and the people who support them, medical professionals and absolutely anybody who wants to know more about what makes the brain tick. In his show Pain, the Brain and a Little Bit of Magic, he collaborates with Naive Theatre Company, using poetry, music and a bit of stand-up and an oversized interactive model of the brain, to bring what’s described as an optimistic message of how chronic pain may be better understood and treated.
Jones: We thought of it originally as just a way of bridging the knowledge gap. But now we’re thinking about it a little bit differently, and perhaps a way to really bring together the pain community and all the people that are involved in that. So what’s made us think about that a little bit more is that we’re now developing some new brain-based therapies to treat chronic pain more effectively. So we’re doing that in quite close collaboration with our patients. We’re now thinking actually that Pain, the Brain and a Little Bit of Magic could not just be a vehicle for explaining about that, but actually as a kind of catalyst for bringing these groups together in a sort of collaborative way.
Evans: What sort of therapies are you developing from this then?
Jones: Mainly based on the work we’ve done over the last three decades. We’ve done a lot work on experimental placebo, and discovered doing that process that when we’re expecting to have a positive response from a placebo intervention, the brain expresses more alpha waves, particularly in the frontal and insular cortex. We didn’t really know what that meant, then one of our PhD students, Kathy Ecsy, did a whole PhD on whether this was important or not. And she did that by applying an alpha rhythm to either a visual or auditory stimulus. To cut a long story short, we found that if you do that, you get a painkilling effect on normal volunteers.
Evans: Let me see if I can get this right. There are alpha waves involved in a particular stage of sleep and they are the restorative, the healing waves, if you like. Sometimes, (you must tell me if I’m wrong here), sometimes those alpha waves are missing in sleep?
Jones: We don’t really know exactly what the role of all these different waves, including alpha waves, are in sleep. But certainly alpha waves are associated with sort of early stages of relaxation and, as you say, restorative sleep. We know that patients with chronic pain particularly complain about poor sleep [but] we don’t really know what the relationship is between the sleep and the chronic pain. Some of my colleagues think that it’s the poor sleep that generates the chronic pain. The nub of it is, we don’t really know.
There is also quite a lot of evidence from other sources that alpha waves may be important in controlling aspects of sensory experience. What we now think is that alpha is probably quite important in the kind of top-down control of how we feel. So we’re developing a platform. It’s a technical platform and the idea is that patients will be able to use this in their own home. The actual platform will be downloaded on either a laptop or their smartphone. They will also have an individualised EEG cap, which they’ll be able to just plonk on their head. Because there’ll be wireless communication between their smartphone and their brain, they’ll be able to see how much alpha they’re expressing in their brain. If they look on their pain diary, and they notice their pain is pretty bad, has really been getting worse and worse in recent times, then they might decide to engage with a number of options, which will be available on this pain platform.
At the moment, the two main options are one probably more for acute, so recurrent acute pain that a lot of these patients experience. They’ll be able to plug into an alpha entrainment programme that will just allow them to experience alpha either visually or with an auditory input. They will choose how long they want to engage with that, probably twenty minutes at a time. So if they’re getting particularly bad pain that’s interrupting their reading or watching television or whatever, they’ve got something that they can engage with for a short period of time. So we’re just testing out whether that actually works for chronic pain patients at the moment.
The other aspect is to try and train the brain in a more long-term fashion to express more alpha. With that, they’ll be able to look at what’s going on in their brain on their smartphone again, and then train themselves to actually express more alpha waves themselves over a period of weeks or months. We’ve got ideas about kind of doing more sophisticated things beyond that. So it’s a kind of generic platform that allows us to allow patients to interact with their brains in a positive way.
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Using creative writing to better represent the chronic pain experience
This edition is funded by the Arts and Humanities Research Council.
Chronic pain often exists ways that cannot be seen. Due to the intangible and ambiguous nature of many chronic pain conditions that lack clear-cut causes and treatment, patients feel frustrated when communicating with healthcare professionals, personal networks, and the public at large; they feel ‘invisible’. Lancaster University’s English and Creative Writing department has built a research network to collect short-form ‘flash’ illness writing; pieces that aim to better represent people’s experiences of chronic pain.
In this edition of Airing Pain we hear from the project’s Principal Investigator Dr Sara Wasson about the many components that make up the project, its origins, and the goal of conveying the experience that millions of people go through every day.
Issues covered in this programme include: Arts and crafts, communicating pain, creative project, creative writing, culture, describing pain, educating healthcare professionals, explaining pain, inequality, intersectionality, misconceptions, muscle spasms, personal experience, poetry, representation of pain, spasmodic torticollis, stigma, visibility and writing.
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