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Stress can perpetuate pain

Friday, October 16, 2015
Dirt Under the Nails

It is generally accepted that emotional or psychological stress can make one’s physical pain worse, but there is now a new concept of “stress-related pain” that takes this idea even further. It assumes that the patient’s psychological and emotional factors are the primary cause of the patient’s pain. The fact that there is an actual diagnosis of stress-related pain speaks to the remarkable role stress can play in pain.

The purpose of this article is not to focus on stress-related pain as a diagnosis. Rather, I would like to discuss how stress can present itself in a physical way. I am not a psychologist, but in my practice I do see the manifestations of stress in the body and it is my job to identify them and offer proper referrals to the relevant qualified professionals, with the approval of the physician. 

There are a number of theories that attempt to explain why stress can cause or perpetuate pain. The common thread in all of these theories is that psychological and emotional stress cause some type of physical change in the body, resulting in pain. It is important to note that it is unfair to brush off a person’s pain as “all in his head.” The pain is real.

In Trinidad, we do not see official diagnoses of stress-related pain much at all…at least in physical therapy. Usually, patients in chronic pain related to stress go through all the medical diagnostic tests, which they should, in order to rule out certain issues. They have MRI’s, X-rays, CT Scans, etc, and are usually diagnosed based on the results of these tests, despite the fact that their symptoms may not match the test results. Treatment then ensues for such diagnoses, but the patient seldom improves because the stress is not targeted as a cause.

Pain, and its lack of improvement can cause a vicious cycle that leads to further stress and perpetuation of pain. It is a difficult cycle to break—pain leads to the patient becoming more timid and fearful of movement. This fear can be made worse by lectures and diatribes from healthcare providers and family, telling the patient to “take it easy.”

This causes what we call “fear-avoidance” of activities and the patient becomes unnecessarily limited in his daily and leisure activities. Fear avoidance is a common occurrence in many people with pain. The limitations in movement from avoiding activities lead to deconditioning and muscle weakness, which can then make pain worse. The cycle continues with more fear, more avoidance, more deconditioning. and more pain. In severe cases social isolation, depression and anxiety ensue. 

Often, it is only when all medical treatment has failed, that healthcare professionals begin to consider psychological stresses as significant contributors to pain. By then, the patient is so far into the pain cycle, that significant psychological intervention is necessary. Yet, many patients are reluctant to see a psychologist, despite education on the need for such intervention.

Breaking this cycle involves a team of healthcare professionals. A one-man show is sure to fail in a case of stress-related pain. Effective treatment begins with the physician, who the patient initially seeks out because of the presence of this pain. He/she performs all the relevant medical tests to rule in/out certain causes for the pain.

Early flagging of certain signs and symptoms of stress and anxiety/depression is key to getting the correct professionals involved as early as possible. Once this is done and the physician determines the contributors to the pain, he/she can then refer to these professionals. 

They can and should include a psychologist to help with managing the stress-related issues, and developing coping mechanisms to deal with pain. A physical therapist is also a vital member of this team and will work with the patient on pain management, on reinforcing the coping techniques learned from the psychologist, on increasing his/her strength and endurance, and will take the patient through graded exposure to activity so that the patient can overcome fear of movement and re-integrate into her/his regular activities of daily living and leisure.

Occupational therapists may be necessary team members as they can work with the patient on home and activity modification that can make activities easier, which will assist with increasing the confidence and independence of the patient. Other healthcare professionals who offer appropriate pain management techniques may also be involved.

As scientist Hans Selye once said, “It’s not stress that kills us, it’s our reaction to it.” We all have different ways of dealing with stress. But when it begins to affect us by causing pain, it’s time to make some changes and get the right professionals to help. 

• Carla Rauseo, DPT, CSCS, ATRIC is a Doctor of Physical Therapy and a Certified Aquatic Therapy Rehabilitation Instructor at Total Rehabilitation Centre in San Juan.


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