Stress + Pain
May is Mental Health Awareness month.
I am not a mental health expert; however, I would like to use this opportunity to talk about the relationship between psychological stress + musculoskeletal pain and what you can do about it. Whether you suffer from years of intermittent low back pain or recently suffered a traumatic injury that is lingering, external stressors in your life may be playing a larger role in your body’s pain response than you realize. This absolutely does not mean the pain is “in your head.”
It means stress causes chemical responses in your body that play into the extremely complex neurologic cascade that lead to physical pain.
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If science isn’t your jam - head down to the Action Plan ;)
The human body is extremely resilient and has highly organized processes after physical injury. This response comes from your immune, nervous, and endocrine systems through neural and chemical pathways. As more research develops, the interconnectedness and complexity of these systems becomes more apparent.
In simplified terms, during an acute response to physical stress/injury the nervous system receives and sends messages that lead to an increased production of hormones (epinephrine and cortisol) that increase your heart rate, increasing blood flow to in-need areas as a defense mechanism known commonly as ‘fight or flight.’ In turn, this increased hormone production leads to an immune response we know as ‘inflammation.’ This process is vital to the protection and healing of an injury. In the short term, it is beneficial and necessary.
Interestingly, the body goes through a similar response in the presence of a non-physical stressor; i.e. the loss of a job, the death of a loved one, a rapid change to our normal routine (read: COVID-19).
So how does this response lead to increased pain?
The chemicals released during a stress related inflammatory response lead to increased sensitivity of the nerves related to the body’s perception of physical pain.
Think of your body as a home and your nervous system as an alarm system. Under the stress response, the alarm may be triggered by a non-intrusive threat. If this heightened response is not addressed, it becomes more and more sensitive over time.
Chronic stress and pain related to depression, anxiety, and PTSD can place the body in this state of overdrive for long periods of time. This can cause measurable volume reductions in structures of the brain that help with regulation and coping of pain (hippocampus and amygdala).
This can ultimately lead to a harmful cycle of avoiding potentially painful movements, in turn, leading to less participation in activities. This lack of exposure then further increases the sensitivity of the system.
ACTION PLAN
Let’s circle back to the resilience of the human body.
Neuroplasticity is the brain’s ability to form new connections/pathways and re-organize already existing pathways based on exposure and environments throughout life. This phenomenon can lead to reversal of the brain structural changes mentioned above.
As a physical therapist, I consider myself a movement expert. Assessing restrictions, compensatory strategies, measuring strength - all that fun jazz. I can prescribe exercises based on these impairments and address physical limitations for months, but if we do not address the psychological component of pain then we will never reach maximal potential. This is true for an athlete successfully returning to sport 1 year after ACL reconstruction as well as for an individual with 20 years of chronic back pain picking up his grandchild. Confidence and (inversely) stress related to these activities will affect a person’s ability to do them successfully.
So how do we address this less measurable but equally important piece of the puzzle?
1. HAVE A SUPPORT SYSTEM
As mentioned earlier, I am not an expert in mental health but respect its importance. There is immeasurable value in speaking with a trained mental health professional.
There are lot of different professionals with alphabet soup after their names.
Here is a guide written by Physician Assistant, Chandra Goff, PA-C:
Psychiatry: A psychiatrist or psychiatric clinician has a medical education and their practice is usually focused on diagnosing mental illnesses and prescribing medications. Most generally don’t provide talk therapy. Types of credentials psychiatric clinicians have are medical ones including PMHNP, NP, MD, DO, or PA-C.
Psychology: A therapist (AKA counselor) focuses on talk therapy (psychotherapy), which includes many different treatment modalities (e.g. cognitive behavioral therapy, etc.). They don’t prescribe medication. Types of certifications a credible therapist will have include LMFT, LCSW, LMSW, LMHC, LPC, LCPC, PsyD, or PhD in psychology.
Chandra recommends “For both clinical anxiety and depression, therapy and medication have each been shown to be more effective when used together rather than choosing one or the other. A therapist is generally the best place to start, in my opinion, if you're having a hard time and don’t have any known serious mental health diagnoses. They can recommend other providers if they think you would benefit from it. Primary care providers can also help with diagnosing, prescribing, and referrals for mental health.”
Not every injury will require professional intervention for physical or psychological therapy. Every injury varies person to person. Two people with neck pain can present very differently and should be treated on an individual basis- from a mind and body standpoint.
If you are not sure if your injury warrants either physical or psychological therapy - reach out to a professional for more guidance.
If you are on the giving side of a support system, try to:
Provide ongoing support. A lot of folks experience a ton of support immediately after an injury but that dwindles over time. Reach out regularly, as they may feel like a burden to talk about continued pain or difficulties. Offering to help with heavy grocery bags or going on a short walk together can be highly appreciated gestures.
Encourage professional guidance. The most supportive spouses and friends are likely not professionally trained, and even if they are, a degree of separation and support is vital. You can offer to make an appointment or help find a provider.
2. MAKE STRESS MANAGEMENT A PART OF YOUR DAILY ‘EXERCISE’ PROGRAM
We cannot eliminate stress from our lives, but we can change how we manage it. Meditation has been practiced for thousands of years and has withstood more recent rigorous research trials in efficacy. Tried and true, it has multiple benefits -
stress reduction being one of them.
There are many different types of meditation and it may take trial and error to find which one(s) work the best for you. According to the Mayo Clinic, here are a few different types:
“Guided meditation. Sometimes called guided imagery or visualization, with this method of meditation you form mental images of places or situations you find relaxing. You try to use as many senses as possible, such as smells, sights, sounds and textures. You may be led through this process by a guide or teacher.
Mantra meditation. In this type of meditation, you silently repeat a calming word, thought or phrase to prevent distracting thoughts.
Mindfulness meditation. This type of meditation is based on being mindful, or having an increased awareness and acceptance of living in the present moment.”
Just like any form of exercise or addition to a routine, it takes practice. Try keeping a log of the type you do and the duration. This will not only track your progress but also hold you accountable to make it a part of your routine. Be careful not to be hard on yourself if it is a short duration or is irregular completion.
Start small, appreciate the successes, and allow yourself to grow in your practice.
3. GET THOSE ZzzZzzzzZzzZ’s
A good night’s rest is important for a laundry list of reasons including muscle recovery and stress reduction. This importance is well established by both research and likely your parents while growing up. The current recommendation for adults is 7-9 hours per night. Unfortunately, stress can lead to reduced sleep quality and duration and in turn, create more stress in your inability to fall asleep.
Here are a few tips by the American Academy of Sleep Medicine to get that A grade sleep quality:
“The best time to go to bed is when it’s around your usual bedtime (not too early, not too late), and that you are feeling that “wave” of sleepiness is arriving. For some people this may feel like alertness is lower, eyelids are heavy, thoughts are slowing down. Learn to “surf the waves” of sleepiness, and “catch” it as your bedtime helps fall asleep quickly.
Unwind at least an hour before bed. This helps prepare your body and mind for rest and sleep.
Do not attempt to sleep when you are alert, fully awake, or distressed. If it is your bedtime and you are feeling this way, take more time to unwind your body and mind before trying to sleep.
Bed is for sleep and sex, not wake activities. It’s tempting to move laptop, phone, TV, and even meals into the bedroom and onto the bed. But doing this, could trick our brain into thinking that bed is a place for waking activities, and not sleep. Over time, our brain learns to be more awake, and not sleepy in bed.
Be wise with use of substances. Avoid caffeine at least 6 hours before bedtime; cigarettes are alerting, so avoid it in the evening; reduce alcohol – you may feel drowsy after drinking it, but it disturbs your sleep second half of the night, not at all helpful for sleep.”
Pain is a multidimensional and complex human experience. Your pain experience is your own and how you cope with it is ultimately your decision. Whether you live with a diagnosed condition or have a worrisome lingering injury, having health care providers who positively contribute to your management system can be beneficial in the long term quality of your life.
Know your pain is valid and something can be done about it.
Peace, Love, and Healthy Amygdalas,
Dr. Katie McWilliams, PT, DPT, CSCS
REFERENCES:
Abdallah, C. and Geha, P., 2017. Chronic Pain and Chronic Stress: Two Sides of the Same Coin?. Chronic Stress, 1, p.247054701770476.
Chapman, C., Tuckett, R. and Song, C., 2008. Pain and Stress in a Systems Perspective: Reciprocal Neural, Endocrine, and Immune Interactions. The Journal of Pain, 9(2), pp.122-145.
Sleepeducation.org. 2020. Sleep Tips During Isolation: Preventing Insomnia. [online] Available at: <http://sleepeducation.org/news/2020/04/06/sleep-tips-during-isolation-preventing-insomnia> [Accessed 23 May 2020].
Marksberry, K., 2020. Stress Effects - The American Institute Of Stress. [online] The American Institute of Stress. Available at: <https://www.stress.org/stress-effects> [Accessed 23 May 2020].
Mayo Clinic. 2020. A Beginner's Guide To Meditation. [online] Available at: <https://www.mayoclinic.org/tests-procedures/meditation/in-depth/meditation/art-20045858> [Accessed 23 May 2020].
McAllister, PsyD, M., 2020. Stress, Inflammation And Chronic Pain. [online] Instituteforchronicpain.org. Available at: <https://www.instituteforchronicpain.org/blog/item/152-55stress-inflammation-and-chronic-pain> [Accessed 23 May 2020].
