Patient Information > Pain Management > Complementary

Physical therapy

There are many forms of physical therapy some of which are well known such as physiotherapy, chiropractic and osteopathy, massage etc. These are generally hands-on therapies where most of the work is carried out by a practitioner.

Physical and Movement  therapy

These include taught techniques which are aimed at healing the body and mind such as the Alexander technique, Feldenkrais, Body-Mind Centering and many others. These may include a combination of hands-on work and movement. They encourage participants to take an active role in unravelling chronic pain, injuries, poor posture, emotional difficulties etc. They aim to encourage coordination and flexibility, expand creativity and increase quality of life.

If you are considering any type of complementary therapy, it is important to check that the practitioner is registered, certified, properly trained and adheres to a professional code of practice. Some therapies in some countries are in the early stages of developing professional associations for practitioners.

Pilates is an example of a movement therapy which has become popular in some countries including the UK. However few people will know that there are several types of Pilates and in the UK there is as yet no professional association for those who deliver courses. There is a foundation which provides a list of accredited teachers both in the UK and Internationally who abide by the foundations's Code of Conduct and Ethics. Full membership is an indication that a Pilates Teacher has successfully completed a Foundation training programme.  

Biodynamic psychotherapy includes therapies such as biodynamic massage. We would be interested to have feedback from those with pelvic pain who have tried these approaches.

For some people simply taking up a form of dancing for example ballroom, latin, line dancing, mo-jive etc could have great benefit by increasing mobility and improving mood.

Why do I need to see a psychologist? Don’t you believe I’m in pain?

Helen Poole & Peter Murphy

Helen Poole PhD, CPsychol, Senior Lecturer, School of Psychology, Liverpool John Moores University and Visiting*Honorary Research Fellow, Pain Research Institute.

Peter Murphy PhD, MClinPsych, Consultant Clinical Neuropsychologist & Director of the Pain Management Programme, The Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool

The Pain in Europe(1) survey suggests a third of UK homes have at least one chronic pain sufferer, with one in seven of us suffering at any time. As pain persists and becomes chronic, it can affect not only the individual sufferer, but also their family, friends and others. So even if you don’t suffer from chronic pain yourself, you probably know someone who does.

Many health professionals may be involved in the treatment of people with pain. In this article we aim to look at the role psychology has in our understanding and management of pain.

So what’s psychology got to do with pain?

This is often the first question that people ask when told they are going to see a psychologist. It’s sometimes driven by the worry that others must think they’re ‘crazy’ or don’t believe they have pain at all and that it’s all in their head. But that’s certainly not the case at all. The way we think and feel plays a big part in our perception of pain. We all have a normal psychological response to pain, and we know that people with the same amount of pain don’t always respond to it in the same way. The way we think can lead us to experience greater pain intensity. This doesn’t mean that the pain is due to the way we think, but rather, that the way we think and feel about pain affects how we perceive it, as well as the extent to which it affects other aspects of our lives.

The International Association for the Study of Pain (IASP) define pain as:

‘An unpleasant sensory and emotional experience associated with actual and or potential tissue damage, or described in terms of such damage’

This widely accepted definition shows that both physical and psychological factors are important. Indeed psychological factors such as thoughts and emotions should not be thought of as secondary responses to pain, but are instead things that combine with physical and sensory aspects to control and regulate pain. As such, our perception of pain can be influenced by personal characteristics; including; what the pain means to us, our memories of previous pain, our mood and the beliefs we have about our ability to cope with pain. This helps us understand why people vary in their experience of pain and reaction to it. We also need to appreciate the role of social and cultural factors. As infants and throughout life, what we learn about pain and how others react to it can influence our thoughts about pain and ultimately the way we behave in response to it.

If you have chronic pain, consider this: you may be able to recall days when the pain was bad and bothered you, and other days when the pain was just as bad but didn’t bother you as much. What was different? Perhaps in one case you were home alone, having told your friends you couldn’t meet them , feeling isolated and miserable, thinking about the future and how you might cope, maybe feeling frustrated about pain preventing you from doing some of the things you used to enjoy. In the second case, you may have also been home alone, but engrossed in an activity that you enjoy, perhaps reading a book or watching TV. Again, these examples show how thoughts and feelings can seemingly ‘increase’ pain as you focus on it and its impact, as well as ‘reduce’ pain when your attention is directed away from it. This isn’t to say that all we need do to reduce pain is simply distract our attention away from it. Although distraction can help, it’s often only effective in the short term, and it’s just one of a range of techniques we can use to help us manage pain in the longer term.

Psychological factors related to pain

Just as the way that we think and feel about pain can affect our perception of it, the presence of pain can in turn affect how we think and feel. This then can have an impact on other aspects of life, such as our relationships with family and friends. Again, it is important to note that as individuals we differ enormously in our responses. Not everyone with chronic pain will become distressed or disabled by it, unfortunately some do, and for these people, recognizing that distress is common can be reassuring.

Emotions

Anxiety: Many people faced with a chronic condition become anxious, for example about the effect it will have on their life, and this is normal. Any pain can lead to distress, but pain that persists over months or years with no hope of recovery may make this worse.We know that increased anxiety is linked to higher levels of pain intensity. This in turn can fuel more anxiety as we worry about the pain, again inflating the pain; creating a vicious circle of increasing pain and anxiety. If an explanation for the pain problem hasn’t been found, anxiety about when the pain will end can continue indefinitely. Those of us who tend to be worriers by nature can get so anxious we become overwhelmed and this may lead to depression.

Depression: is common in people with chronic pain and has been linked to higher levels of pain. Low mood, including persistent feelings of anger, frustration and guilt can occur for many reasons. People who no longer do the activities they used to, miss the pleasure they used to get out of them. They tend to withdraw from other social, work, and/or leisure activities, which in turn can affect their relationships with others and contribute to a reduction in overall quality of life.

Feelings of anger and frustration can easily be increased in chronic pain as for example people search unsuccessfully for an explanation for their pain, or treatment that helps. When there is nothing specific to direct the anger at, other people often bear the brunt of it. For some, this puts a further strain on relationships. Guilt may result as we view ourselves and our behaviour in a negative way, and this can lead to further feelings of hopelessness and helplessness.

Pain often leads to us avoiding things we fear will make the pain worse. In this way fear can influence our pain response as it leads to avoidance of activities. In pain that has just occurred this makes sense, it protects us from further harm and increases our chances of survival. However, over time, as pain becomes chronic it is less helpful. In this situation, fear may result in further avoidance of activity associated with pain and if this is prolonged it can lead to disability and a vicious cycle of inactivity.

Cognitions

Cognitions are simply thoughts or ways of thinking about things. They are linked to emotions in all aspects of our lives. The way we think about something affects our feelings about it and vice versa. In the same way that emotions can influence the perception and impact of pain, so too can thoughts.

People with chronic pain often complain of poor concentration, poor memory and reduced ability to complete other cognitive tasks, e.g. things that require us to pay constant attention, like driving. This reduction in our cognitive abilities may be due to the distress related to anxiety and/or depression. Distress can affect our thought processes making them slower and less responsive. Unfortunately, some medications known to benefit pain are also known to affect these processes.

Attention: pain demands our attention, but some people are more attentive to painful sensations than others. Those of us with heightened attention to pain and bodily sensations are more likely to report increased pain related disability and distress. In contrast, those who pay less attention to their pain, or distract themselves from it, generally report lower levels of pain and distress. Again, this highlights how some strategies, such as distraction might be harnessed and used to help us deal more effectively with pain.

Coping: refers to our ways in which we deal with pain on a daily basis. Many different ways of coping have been identified, for example: reinterpreting pain sensations (thinking about them in a different way), taking medication, praying, diverting attention away from the pain and increasing activity to name but a few. Some of these may be more successful than others at reducing pain, but researchers are still debating what the best types of strategy are. What seems to be important is finding out what works best for you. Those who have belief in their ability to control pain, i.e. to be successful in their use of coping strategies are more likely to report increased functioning, reduced pain intensity and less distress.

Catastrophising: This particular style of thinking has been widely researched in many different kinds of pain conditions. We all catastrophise at times, and this is not restricted to thoughts about pain. Perhaps you’ve been stuck in a traffic jam, late for an important appointment, feeling helpless as there is no alternative route, you begin to worry about all the negative things that could happen if you’re late or miss the appointment altogether…and the longer you’re stuck, the more you worry and the worse it gets? that’s an example of what catastrophisng is like. It can be viewed as a continuum, a little catastophising may be helpful sometimes, worrying about being late for an important appointment might have made us set off in plenty of time, just in case the traffic was bad. In this sense catastrophising could be described as part of the normal process of worrying about pain. Except that in a few people it can be made worse by chronic pain and can become excessive.

High catastrophisers worry about pain, ruminating over it (I can’t stop thinking about how much it hurts), and this magnifies it (something serious might happen) leading to thoughts of not being able to cope and feelings of helplessness (there’s nothing I can do to reduce the pain). This type of thinking can lead to increased distress and has been shown to be related to poor adjustment to chronic pain. In contrast, low levels of catastrophising are related to better adjustment, less distress and as a consequence, less pain.
This last point suggests that as psychology is involved in the perception of pain, then it may be possible to involve it in the treatment of pain. For example, we know that some patterns of thinking increase the experience of pain and its effects, whilst others reduce it. It is logical therefore to try and use this information to educate people, teaching them more ‘helpful’ ways of thinking about pain and its effects. These ideas are outlined in a little more detail below.

PSYCHOLOGICAL MANAGEMENT

Psychological interventions tend to promote self management techniques focusing on emotional, cognitive and behavioural aspects of pain. Pain Management Programmes based on this type of approach have been shown to be effective in chronic pain. Typically these programmes contain a number of components, including; education, coping skills training, relaxation and goal setting. They address peoples’ beliefs by educating them about pain and its effects, reduce anxiety and stress by teaching relaxation techniques and increase personal control by teaching coping skills. These techniques can help with the anxiety and distress associated with pain, but may not have a direct effect on pain itself. Nevertheless, they can help indirectly. For example, teaching distraction techniques will keep you busy and may improve your mood, which in turn will have an effect on pain. In addition, they can

Education: People with chronic pain have a tendency to seek reassurance and many worry that the pain is due to something serious. Reassurance through education can reduce the anxiety and distress associated with pain. Information about the causes and consequences of pain can lead to greater understanding and influence beliefs about pain, enhancing feelings of control over pain.

Coping skills training: This can include stress management techniques and relaxation as well as instruction in other coping techniques.

Relaxation is a vital skill, it can reduce feelings of anxiety and tension and increase people’s sense of well being, which in turn may reduce pain intensity. Relaxation can be used as a coping strategy, but is a difficult skill to learn. Like any other new skill, it takes time, practice and commitment to succeed. However, once mastered it can increase a persons feelings of control and belief in their ability to cope with the pain.

Cognitive restructuring: This is designed to change the way people think about their pain. It helps identify patterns of unhelpful thinking, irrational beliefs and coping behaviours. At the same time, more effective ways of coping can be encouraged which in turn improves self belief in ones ability to control pain.

Distraction: when attention is focused away from pain, we can experience pain as less intense. Mental imagery techniques are often used to aid distraction and it has been found to be a helpful strategy in the short term, particularly when the pain is less severe. A limitation of this method of coping is that it is short lived, as when we stop using distraction techniques, attention turns to the pain again.

Problem solving: people with chronic pain may become easily stressed and overwhelmed by everyday activities. Help with problem solving can reduce this.

Goal Setting and pacing: People with chronic pain sometimes have cycles of over and under activity. They carry out an activity till the pain stops them and this then forces them into a period of rest which reinforces the avoidance behaviour. Goal setting and pacing techniques can be used to break this cycle.

Some of the techniques described above can be difficult to use when a person is extremely distressed by the pain and its consequent effects. In these instances, the psychologist may offer individual supportive psychotherapy or counselling.

Summary
This article has provided a very brief review of the role psychology has in the pain perception, highlighting how individuals vary in their responses to pain. We have also described how our knowledge of psychological factors has influenced the way in which pain is managed and suggested ways that people with chronic pain can learn simple strategies to help them regain control and cope with their pain more effectively. We hope the article has gone some way to dispelling the myth that seeing a psychologist means others don’t believe the pain you have.

Helen Poole & Peter Murphy are conducting a research project to assess the impact neuropathic pain has on quality of life.

(1) Pain In Europe Survey 2004

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