The pain cycle, the role of strength, physical activity, sleep and nutrition in managing it - CREDITS Versus Arthiritis

1. Chronic Pain
Many of us find it difficult to look after patients with chronic pain, and life can be very difficult for patients experi-
encing chronic pain.
It feels like we are entering a new era in the management of chronic pain. The paradigm of using the ‘analgesia lad-
der’ and just working our way up has shifted entirely. We now know that for the vast majority of patients with
chronic pain, there is no tablet cure. There is also substantial distress, disability and loss associated with chronic
pain, and many patients are feeling ‘abandoned’ in light of the opiate crisis and resource limitations in secondary
care pain services.
We need to go back to the drawing board and look at this from a new (old) perspective.
This article offers you an introduction and broad overview, and we will cover some of these subjects in more detail
on the webinar.
How much of a problem is it?
It is a huge problem! Some stark statistics:
• 1 in 10 adults worldwide are affected by chronic pain. It is more common in older adults (BMJ Open-2018-
025743).
• The Global Burden of Disease Survey Study showed that musculoskeletal disorders were the leading cause of disa-
bility worldwide in 2015 (Lancet 2016;388:1545).
• Musculoskeletal (MSK) disorders now have the second greatest impact on the health of the UK population after
cardiovascular disorders, taking into account both death and disability (DALYs) (Lancet 2016;388:1603).
This is expected to increase due to rising levels of obesity, sedentary lifestyle and an aging population.
So, from a clinical point of view and from our patients' perspective, this is a HUGE issue and one which most of us have
received significantly less training in than we need!
What is chronic pain?
Simplistically, chronic pain is defined as pain lasting for more than 3 months when normal tissue healing would be ex-
pected to be complete, though the changes that lead to it may start to occur well before that point in time. It is asso-
ciated with clear neurobiological, psychological and behavioural changes (International Association for the Study of
Pain):
• The nervous system remodels, and changes in grey matter can be seen on MRI scan.
• The function of the nervous system changes, and both peripheral and central sensitisation can be seen.
• Thoughts, feelings and behaviour may change, contributing to change in function, and disability and distress.
• Fear avoidance behaviours can result in physical deconditioning and disuse syndrome.
It is different from acute pain for which a noxious stimulus can usually be found. Acute pain is beneficial because it is
protective (removes the individual from harm) and promotes healing and recovery by triggering physiological pro-
cesses.
Chronic pain is maladaptive and causes the individual to mount protective mechanisms, e.g. avoiding movement and
activity which only serve to limit recovery and can lead to significant disability.
What is sensitisation?
This is part of the ‘neuroplasticity’ we now understand as essential in the development of chronic pain.
Peripheral sensitisation is increased responsiveness/reduced threshold of nociceptive neurons in the periphery to
stimulation. Acutely, it can serve as an adaptive and protective mechanism to restrict movement, for example, and
avoid further damage, allowing healing to take place. As the tissue heals, the concentration of inflammatory
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2. mediators in the tissue declines, and, with it, the sensitivity of the nociceptors should return to baseline levels. How-
ever, this is not always the case.
Central sensitisation is an increased sensitivity of the central nervous system to both noxious and non-noxious periph-
eral stimulation. Essentially, the brain has become more sensitive and perceives normal sensations from the environ-
ment as pain. This is part of the explanation for why some people continue to experience pain well beyond the time
when tissue healing has occurred and there is no further noxious stimulus.
It is not a diagnosis in its own right but a phenomenon that can accompany a wide range of pain conditions, e.g.
chronic pain, osteoarthritis with central sensitisation (DTB 2019;57(4):60).
Potentially, anyone experiencing a pain can develop central sensitisation but only a small proportion actually do. Hav-
ing said this, central sensitisation is much more common (and probably a fundamental part of pathology) in some con-
ditions, and less common but with significant impact on prognosis in others:
The pain cycle
These phenomena can result in individuals entering the ‘pain cycle’. This is clearly illustrated in this great resource
from Live Well With Pain (see below).

3. Chronic pain needs a different approach
The appropriate approach to acute pain is to treat it as a symptom of the underlying cause. The main focus remains
the diagnosis and management of the underlying pathology, and short-term analgesia as required.
The problem arises when the same approach is used for chronic pain. In such cases, the underlying cause may not
be known or may not be treatable.
• Chronic pain causes structural, functional and chemical changes in the central nervous system of the individual,
leading to increased responsiveness to painful and non-painful stimuli (central sensitisation).
• The individual may look the same from the outside but their nervous system has changed dramatically; this may
be reflected in their mood, and the way they think and behave.
Stop the search for a cure…
Nearly every patient we see with chronic pain hopes for a cure. At present, as clinicians, we know this usually isn’t pos-
sible. However, how often do we explicitly say this? This collusion could be detrimental.
Have you ever thought how many medical problems we actually cure? It is surprisingly few; we manage most illnesses.
If we don’t understand the difference between acute and chronic pain, we fall into the trap of a recurrent cycle of
looking for causes and cures. There are real risks attached to the ‘pursuit of cure’, including (Pain Treatment Centres
at a Crossroads: A practical and conceptual reappraisal 1996:101):
• Repeated and unnecessary diagnostic tests which may have false positive results, increasing anxiety.
• Maintaining a belief that something is broken and can be fixed.
• Risks of diagnostic studies, interventional procedures and surgery, and associated healthcare costs.
• Delay or failure to provide rehabilitation contributes to maintenance of disability.
• Reduced chance of return to work.
• Perpetuating patient passivity.
So, once appropriate investigations have been done to rule out pathology, it is perfectly reasonable to go on to con-
sider and manage chronic pain as a long-term condition and promote a self-management approach. We do this all the
time for problems such as irritable bowel syndrome; no one attempts to cure it.
However, so far, this concept has not been widely transferred to the management of chronic pain.
Give a clear diagnosis
Your diagnosis is ‘chronic pain’.
These pathological changes, symptoms and signs suggest that chronic pain should be considered a disease in its own
right (Anesth Analg 2004;99:510).
Therefore, it is necessary not only to assess and treat the underlying cause of pain where possible, but also to treat
the whole host of its consequences – including sensitisation, mood, cognitive changes and disability.
It is also essential that we help our patients with chronic pain understand what is going on in their bodies, and
change our consulting behaviours to reflect this.
If we can’t use opiates or gabapentinoids, what can we do?
We now know that for the majority of chronic pain patients, the harms of opiates and gabapentanoids outweigh the
benefits, particularly for long-term use. Simple harms include sedation, nausea, constipation, depression and sexual
dysfunction, as well as tolerance and dependence, an increased risk of remaining off work and more disability.
There is still a lot we can do to build patients’ ability to self-manage. The headlines:
• Hear the individual’s pain story, understand ‘what matters to them’ and utilise drug-doctor skills.
• Offer a clear explanation of what chronic pain is and factors that can make it worse or better.
• Be honest about the role of medication and what it can and cannot do.
• Coach patients towards self-management.
• Share and signpost resources to support self-management.
• Promote movement as a form of medicine.
• Focus on function as much as pain, and use functional goals.

4. • Use a biopsychosocial approach (much like we do with depression) to tailor management options towards the in-
dividual.
There are lots of resources to support us as clinicians in doing this. Some of the best are listed below and we will talk
in more detail about this on the webinar. It can be illustrated, in part, by the ‘self-care cycle’:
The biopsychosocial model in chronic pain
We treat the physical, psychological and social problems of our patients on a daily basis, and use the biopsychosocial
model routinely for medical problems such as depression or anxiety.
But many of us do not routinely apply the biopsychosocial model to chronic pain - and we need to. Chronic pain is a
complex interplay of physical, psychological and behavioural factors. Over time, patients need a management plan
that considers factors in ALL these areas.
We do not have to do all this in a 10-minute consultation. What this gives us is lots of small things we can work
through as part of an ongoing clinician–patient relationship. It is a refreshing angle as it offers our patients choice
and hope in a range of things that may make an impact. It also, over time, allows us to hand over responsibility and
to coach rather than tell.
You can use the pain and self-care cycles above to encourage patients to identify what is important to them (PDFs are
available on Live Well With Pain).
Management options
Key areas: Strategies we can use:
Pain Helping patients to have a clear understanding of their pain will make a big difference:
• Identifying and explaining types of pain (nociceptive, neuropathic, chronic).
• Explaining peripheral and central sensitisation.
• Hearing the whole ‘story’ of the pain from beginning to end may help us understand the bigger picture.
Mood Ask about mood.
• Is there psychological distress?
• Identify depression and anxiety (PHQ-9 and GAD-7).
Both are more common in chronic pain and they interact with each other in terms of symptoms and function,
but also neurobiological pathways.
Managing mood disorders improves outcomes in chronic pain.

5. Psychological therapy and medication, as needed, are the mainstay of treatment, just as in any other context.
Cognitions Individuals think about their pain in different ways which can either help or hinder their ability to manage
their symptoms.
We can spot patients with ‘unhelpful’ cognitions and prioritise psychological (usually CBT-based) input to
help. Tools such as STarT Back work on this principle of identifying unhelpful cognitions.
We might spot ‘unhelpful cognitions’ in our consultation in phrases such as:
“I can’t stand this; it will never end” (catastrophising).
“It’s taking over my life” (magnification, rumination).
“Something must be going on in my back and until we find out what it is, I’m not getting more active (fear-
avoidance behaviours).
“I can’t cope with this; the physio didn’t do anything” (passive coping).
“I can’t do this” (low self-efficacy).
Behaviour Patients who use active coping strategies have less disability and distress due to pain:
• Active coping strategies: patients try to manage pain through their own efforts (exercise, meditation).
• Passive coping strategies: patients rely on other people (e.g. physiotherapist) or drugs to manage their
pain.
To make use of active coping strategies, individuals need a belief in their own ability to perform a task (self-
efficacy). This is not static, and we can enhance this through coaching, feedback and positivity.
Family/social
connections
Social support is generally a positive thing and can act as a buffer against depression, build self-efficacy and
encourage independence (Clin J Pain 1993;9(1):34).
Family and social connections can be a help or a hindrance. Look out for:
• Spousal criticism and hostility which can increase pain intensity (Pain 2013;154(12):2715).
• Solicitousness towards ‘a partner in pain’: This is overprotectiveness, e.g. offering excessive help, too
much concern, discouraging activity, taking over usual tasks (they reward passive behaviours).
• Punishing spousal responses (!) in the context of a loving relationship; these actually lower levels of disa-
bility, e.g. Come on Jim, get off your backside and help with the washing up.
Discussing these things openly may help home dynamics.
Safeguarding
We should also be aware of safeguarding issues that may be occurring, e.g. domestic abuse, past-history of
physical or sexual abuse, and remember to think about any children in the family – what is life like for them?
Activity Building confidence and self-efficacy in increasing activity is a cornerstone of the management of chronic
pain. We can support patients to use strategies of:
• Goal setting.
• Pacing.
• Grading.
This will help build activity into everyday life and promote specific exercises that will help them to manage
their pain (see resources below).
Work Ask about work and what support individuals need to continue or return to work.
Utilise occupational health if it is available. Use MED3 to look at a range of return options.
Remaining or getting back to work despite chronic pain has better outcomes (Scand J Work Env Health
2006;32:257). Certain occupational factors are associated with an increased risk of disability from back pain:
• Low job satisfaction.
• Monotonous work.
• Self-reported stress.
• Impaired workplace relationships.
External charities such as Versus Arthritis, Citizens Advice and ACAS are able to offer patients advice around
employment issues, grants that may be available, etc. Do you have a social prescriber who can signpost?
Sleep Poor sleep makes pain more difficult to manage. Strategies that may help include:
• Sleep hygiene.
• Building activity levels during the day.
• CBT-I.
We should avoid long-term sleep medication.
Medication Analgesics may still have a role in managing flares of pain but should be linked to a functional goal, be time
limited and generally not be on repeat prescription.

6. For those taking long-term opiates, gabapentinoids, z-drugs and benzodiazepines, side-effects may be in-
creasing the negative impact of chronic pain on function.
Working on a plan to reduce these is an important part of future management but cannot be done in isolation
without considering all these other factors.
Interactions
with
healthcare
systems
Offering passive treatments and encouraging patient dependence is NOT helpful. We need to avoid:
• Mixed messages.
• Excessive and inappropriate investigation.
• Long periods on waiting lists.
• Collusion!
Comorbidities Chronic pain is often not a condition in isolation. Don’t forget the bigger picture.
For some long-term conditions, more aggressive management may improve the pain, e.g. in painful diabetic
neuropathy, more aggressive control of blood sugar, BP and lipids may have an impact.
Substance
misuse
Look for and recommend treatment for substance misuse, including alcohol.
We hope this gives you some ideas to try out. Please do join us for the webinar to learn more.
Chronic pain
• Any pain lasting for longer than 3 months.
• A huge global health problem.
• It often co-exists with long-term MSK conditions such as osteoarthritis and back pain. BOTH must be
addressed.
• Is a diagnosis in its own right.
• Needs a biopsychosocial approach to support patients in managing it.
For clinicians:
Explaining chronic pain to patients
This Brainman video or the Tame the Beast video offer a fantastic explanation of chronic pain – we have
been using it with patients in consultations and found it really helpful.
https://www.youtube.com/watch?v=5KrUL8tOaQs
https://www.youtube.com/watch?v=ikUzvSph7Z4
For all things ‘chronic pain’, Live Well With Pain is a fantastic resource for primary care clinicians and pa-
tients alike – it is well worth investing 15 minutes to familiarise yourselves!
https://livewellwithpain.co.uk
Identifying patients at risk of chronic pain:
The STarT Back tool is designed to do this for patients with back pain. Have a go at using it if you haven’t
already.
https://startback.hfac.keele.ac.uk/
For chronic widespread pain, we can use the StartMSK tool:
https://www.keele.ac.uk/startmsk/
For Patients:
Understanding chronic pain
Versus Arthritis has information resources that explain pain and offer self-management support:
https://www.versusarthritis.org/about-arthritis/managing-symptoms/managing-your-pain/
Telephone support for patients with chronic pain:
Versus Arthritis has a helpline to offer support and information for patients with MSK pain:
https://www.versusarthritis.org/get-help/
Supporting self-management:
Written by a chronic pain patient, The Pain Toolkit features information and resources about effective
self-management of chronic pain. It also has lots of great patient stories:
http://www.paintoolkit.org/
Discussing opiate and gabapentanoid de-escalation
Brainman video explaining simply why opiates may make things worse!
https://www.youtube.com/watch?v=MI1myFQPdCE

7. Live Well With Pain also has some really useful information leaflets that you could use as part of a QI pro-
ject.
Information and support about work:
https://www.versusarthritis.org/about-arthritis/living-with-arthritis/work/
We make every effort to ensure the information in these articles is accurate and correct at the date of publication, but it is of necessity of a brief and general
nature, and this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances.
In particular check drug doses, side-effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do
not accept any liability for loss of any type caused by reliance on the information in these articles.

8. About Versus Arthritis
In 2017, Arthritis Research UK and Arthritis Care joined forces so that we could achieve more for
people with arthritis. In September 2018, we became Versus Arthritis.
Join our professional network and become part of a growing community working together to change
the face of MSK care. We’ll keep you connected with the latest developments in MSK health and
care, you’ll receive bulletins containing practical tips, and development opportunities as well as the
latest Versus Arthritis patient information.
https://www.versusarthritis.org/about-arthritis/healthcare-professionals/the-professional-network/
For you…
• If you’re looking to gain some hands-on, practical training in MSK then check out our Core
Skills in Musculoskeletal Care. Core Skills is designed specifically for GPs to help you feel
confident and knowledgeable in managing patients with MSK conditions. Our e-learning is free
to access and then if you want to build on this with some hands-on learning then come along
to one of our practical workshops running across the UK. Led by a team of GPs with special
interest in MSK, they’ll help you get the basics right in examination and consultation skills.
https://www.versusarthritis.org/about-arthritis/healthcare-professionals/core-skills-in-
musculoskeletal-care/
• We provide all UK medical schools with accessible, relevant, evidence based educational
resources. Our study guide and series of educational videos support medical students and
healthcare professionals to build their skills and confidence in assessing people with
musculoskeletal conditions in order to deliver effective care.
https://www.versusarthritis.org/about-arthritis/healthcare-professionals/clinical-assessment-of-the-
musculoskeletal-system/
• Through our MSK champions programme we are aiming to create leaders of change who are
committed to change in musculoskeletal care. Keep your eye on our website for dates for
applications for the next cohort.
https://www.versusarthritis.org/about-arthritis/healthcare-professionals/msk-champions/
For your patients…
• Order or download patient information leaflets free of charge https://www.versusarthritis.org
• Encourage your patients to call the free Versus Arthritis helpline
https://www.versusarthritis.org/get-help/helpline/
• Signpost to our arthritis virtual assistant, a 24/7 tool that provides fast, easy to access
information https://www.versusarthritis.org/get-help/arthritis-virtual-assistant/
• Explore our online community which will connect your patients with real people who share the
same everyday experiences https://arthritiscareforum.org.uk
• Connect to local groups and find out what’s going on where your patients are
https://www.arthritiscare.org.uk/in-your-area
Join the growing community of healthcare professionals today and, together we can push back
against arthritis.
https://www.versusarthritis.org/about-arthritis/healthcare-professionals/the-professional-network/
For more information contact professionalengagement@versusarthritis.org