From the first moment of pain, we experience a systemic reaction that is not only physical in nature but also cognitive and emotional. This concert of responsiveness is instinctual and beyond our control – and it’s that way for a very good reason. The classic example is to consider what happens when we accidentally burn our hand on the stove. When this occurs, we experience the physical sensation of burning pain and we jerk our hand away from the source. No part of us has to think over if we want to remove our hand, it just happens automatically. At the same time, we experience emotional distress and perhaps fear about the severity of the burn. “Will it blister? Am I going to be able to use that part of my body for the rest of the day?” Cognitively, we explore the extent of the injury as well as consider what steps we need to take next. “Maybe I need to run my hand under cold water or get an ice pack.” We are also actively considering how to avoid this issue in the future. “Do I need to have a hot pad available closer to the stove? Maybe I need to pay better attention when cooking or ask someone else to finish making this meal.” All of these processes happen instantaneously and there’s very good reason for that. These are protective, adaptive strategies that are an essential aspect of our genetic coding, and they serve us well when dealing with acute pain. The difficulty with these connected responses comes into play when our pain moves from acute to chronic.
How we think about and react to pain is perhaps much more impactful than the physical sensation of the pain itself. Ample research suggests this and yet, it feels like this is not discussed in the mainstream very often. An overarching focus in discussions of chronic pain (which is defined as pain that endures for more than three months) revolves around contending with and resolving the physical experience. When we look for assistance managing our pain or professionals to help diminish it, we search for physical therapists, primary care doctors, massage therapists, chiropractors, surgeons, acupuncturists, and medication support, among others. Although each practitioner is unique, this list of providers may focus on pain as a physical sensation and offer up interventions that revolve around exercise, medication, surgery, and a variety of treatments for our bodies. Here’s where a huge piece of the overall experience of chronic pain is missed.
Our perspectives about our pain (the way we respond when that old pain flares up again, the way we think when pain increases, how we react to the sometimes-debilitating experiences of living with pain day in and day out) have a significant impact on our quality of life as well as our future mobility. This is where I’d like to discuss a term in the world of chronic pain research known as fear avoidance. To understand fear avoidance and recognize it in our own experiences of chronic pain, we first need to acknowledge that pain is never siloed in its physical experience. Just like how we react to our hand being burned on the stove with a joint response between physical, mental, and emotional, we have a nuanced connection to chronic pain that involves all three aspects of ourselves. These instincts, which are so helpful in an acute pain situation, become complicating in our experience of chronic pain and can lead to fear avoidance. It makes sense to pull our hand away from a hot stove, but this same instinct becomes inhibiting when our pain is continuous. Let’s take a look at the following hypothetical example to see how this develops.
Mia is an active person and enjoys running several days of the week. One morning, unexpectedly, she feels some pain in her knee while jogging but pushes through to the end of her run. It doesn’t feel great, but it isn’t too bothersome, so she goes about the rest of her day. As the day progresses, things feel “off” and she experiences a growing state of anxiety that sometimes distracts her from other tasks. By the evening, the pain has gotten worse and she now thinks something is wrong. She feels concern – what if she can’t run regularly anymore? What if this is a serious injury? What if things get so bad that walking is a challenge? She ices her knee and decides to spend the next several days resting up, skipping runs until things feel normal again.
After a week, her pain has not changed, and she decides it is time to seek professional help. At this point, with the pain persisting for so long, her anxiety is quite high. She has cancelled walks with friends, and a dinner she had scheduled with a sibling. At work, she tries to stay mostly stationary and once home, she gets into bed where she stays most of the evening.
Let’s say that she sees a physical therapist that prescribes some exercises but tells her she is not cleared to run until the end of their work together. Mia is compliant with the exercises but doesn’t notice a great deal of change in the pain at first. The weeks continue in this manner, with Mia doing her physical therapy but refraining from other movement activities aside from the walking she needs to do at work. After three months in this state, her pain diagnosis moves from acute to chronic, but she still doesn’t feel like she understands what caused the pain in the first place. This contributes to her ongoing anxiety, and she develops a feeling of things being out of control in her body.
While she does notice some overall relief as the pain reduces, she feels depressed that her life has changed so much and fears that she will never get back to a more active lifestyle. She does see friends occasionally, but she feels isolated when they invite her on hikes or bike rides and turns them down often. She is surprised when her physical therapist says that she is cleared to run, as she doesn’t feel pain free. Excited to get back to exercise, Mia goes out for a jog and doesn’t notice an increase in pain during the run, but later that evening, the pain is greater and she feels utterly hopeless.
What we see here is the development of fear avoidance stemming from those instincts not only to shy away from what causes pain in the first place but also developing from Mia’s fear of re-injury. It makes so much sense that Mia would choose rest and would refrain from exercise because of the pain. For acute injuries, this may be the best step, but when pain becomes chronic, our fear avoidance may encourage us to increasingly shy away from movement, which may cause reduced mobility and more pain in the process. Yes, the pain itself is part of the reason that fear avoidance develops – we do not want to feel the pain again or we do not want the pain to increase – but the cognitive and emotional aspects of our response to pain are hugely at play here. Our anxiety about the pain getting worse, our catastrophizing of how the pain will debilitate us, our fears that we will never be pain-free, our mental planning that tells us to stop moving that body part; these are huge factors in how we respond to and manage our pain.
Fear avoidance is associated with much worse outcomes and higher chances of developing progressive disability related to our injury. The vignette above may read as relatively depressing, but I want to assure you that the story is not over for Mia. The next installments for her do not have to be a slow decline into increased pain until she has a knee replacement, which may or may not alleviate the chronic issue. While that can be a common experience for many, Mia has options.
Finding a team of professionals to work with is incredibly important here. Mia may need to look around to find a physical therapist who better understands the pain she is experiencing and tailors an exercise program to help her get back into more movement during treatment. Mia can also benefit on working with a mental health therapist to help identify the development of fear avoidance and start to work on managing the way she conceptualizes her pain and responds to it. This can have huge impacts on Mia’s quality of life, as she forms more confidence in her body’s ability to communicate with her, works on listening, and diminishes the catastrophizing that ultimately encourages her not to move.
Finally, Mia’s pain can be reduced merely by spending more time with friends. Research suggests that folks with chronic pain can increase the emotional distress of their pain by isolating and fixating on the sensation. This is so understandable because in a vulnerable state, we may wish to protect ourselves until we can resolve the pain. However, we can find relief when we connect with others, which can take our minds off of the intense focus it may have on our pain.
If you see yourself in Mia’s vignette, regardless of what type of pain you may be experiencing, I want to reassure you that you are not alone. Chronic pain is an incredibly common experience and the more we acknowledge it and talk about it openly, the less isolating the experience could be. Beyond that, you are not out of options when it comes to working with your chronic pain. There are steps forward that can offer you support, not only for the physical nature of the pain, but the holistic experience itself.