Pain is a human condition that we’ve all experienced at some stage in our lives. It’s also a complex subject that’s been comprehensively studied. Still, our understanding of pain and its management is a science that’s constantly evolving.

Consequently, physiotherapists specialising in pain management are at the forefront of understanding and treating the many Australians living with complex and chronic pain – and there are many!

Statistics show 1 in 5 Australians over 45 live with persistent, ongoing pain. It’s also a huge financial burden, with research revealing the annual cost of chronic pain will climb from $139 billion to $215 billion by 2050!

Tim Austin, a specialist pain physiotherapist, understands pain and its many presentations through advanced education in pain physiotherapy and treating a caseload of clients experiencing acute to chronic pain.

So, what is pain – and how do we treat chronic pain?

Different types of pain

Pain occurs when the brain signals something hurts, causing an uncomfortable, unpleasant feeling. It’s triggered because something is wrong. There are two types of pain, acute and chronic.

Acute
Acute pain is defined as short-duration experiences of pain where there is a clear connection of damage or disease to the pain. An example of acute pain is the sudden response elicited after a cut or broken bone.

Chronic
Chronic pain lasts more than three months or beyond the expected recovery period for an injury or illness. The pain can come and go or be there consistently. Chronic pain can be experienced even in the absence of illness or injury and stresses the body producing physical and psychological symptoms such as:

• Tension
• Lack of mobility
• Lethargy
• Changes to appetite
• Depression
• Anxiety

Treating chronic pain

Physiotherapists are the key clinicians involved in assessing a patient’s ability to move. They provide a comprehensive assessment across many areas, including the impact of pain on:

• Anatomy
• Function/sleep/relationships/workplace
• Belief structures
• Mood and anxiety

Pain specialist physiotherapists then provide psychologically informed treatment across all these areas, explains Austin.

“Psychological principles are utilised to assist a patient to effectively control and manage their pain, even while participating in physical strategies, such as stretching and strengthening.”

Contributors of chronic pain

It is best to understand chronic pain as having a range of contributors rather than one cause, says Austin.

“It’s well-established that muscle weakness, lack of fitness, poor flexibility and fitness are relevant in chronic pain.

“However, pain-related depression, anxiety about the pain, poor advice from health-care providers and certain behaviours from caregivers and support people can contribute to pain perpetuating.”

Decades of evidence support the notion that the nervous system itself adapts, often unhelpfully, to perpetuate the experience of pain.

“Nerves are not simply ‘passive’ conductors of electricity – rather, they adapt to increase or decrease the flow of information. Why do they do this? Fundamentally, the pain system exists not to identify the damage but rather to identify a threat.

“Threats may be damaging situations, but they may not be. Threats of loss of independence, poor sleep, anxiety, and depression all serve to reinforce the pain.

“In many instances of chronic pain, there is no longer any damage, but the nervous system is communicating information “as if” the damage still exists.”

The immune system also works as a trigger (or modifier) of the nervous system.

“Many instances of chronic pain lead to changes in the myriad of immune chemicals in our bodies, which can lead to a feedback loop of increased pain.

“The classic immune triggers of diet, exercise and sleep are all frequently impacted in chronic pain, leading to a downward spiral of further pain.”

The biopsychosocial lens

Pain can be interpreted and treated through a ‘biopsychosocial’ lens, says Austin.

Biological components
• Reduced fitness
• Poor sleep
• Loss of strength
• Medication side effects

Psychological components
• Pain-related depression
• Anxiety
• Unhelpful thought processes
• Stress
• Suicidal thoughts

Social components
• Impacts at work
• Strain on relationships
• Compensation systems
• Health-care sector

“These are not just ‘consequences’ of pain, but feedback into the pain and disability cycle.”

The chronic pain treatment plan

A comprehensive assessment process that addresses the biopsychosocial components is crucial to creating a targeted chronic pain treatment plan.

Education
Individualised education helps patients understand why they are still experiencing pain.

“Often when patients achieve a better understanding of why they are in pain, they become less anxious and stressed and more optimistic about incorporating active strategies, which lead to better pain control and often less pain intensity.”

Physical activity
Increased physical activity almost invariably helps address chronic pain, but this needs to be handled precisely, says Austin.

“There is a great deal of nuance in assisting people to increase activity when their past experiences are almost always of increased pain when they have tried!

“A gradual increase in physical activity in a personalised way that attempts to help a patient return to their specific goals [is crucial].”

Sleep
Sleep loss heightens the experience of pain, so addressing any sleep issues experienced by the chronic pain patient is important.

Diet
Studies show alleviating chronic pain can be linked with diet, including the reduction of proinflammatory foods and an increase in unsaturated fats. Dietary approaches for chronic pain include education on a balanced diet, healthy eating patterns and food supplements where required.

Psychological
Mindfulness, thought-management, pacing and exercise planning are important psychological strategies that can in incorporated into a treatment plan, advises Austin.

Social
Addressing the social aspect of chronic pain is about more than just making the patient feel good, says Austin.

“Helping the patient’s family and friends and dealing with the workplace could also be treatment approaches – not just to be nice to the patient, but to actually change their pain and disability.”

Medications for pain
A plan to reduce medications is frequently misunderstood, says Austin.

“At one extreme, patients may have been introduced to too many medications, which may be causing harm - especially opioids.

“A reduction in medications may be desirable. But it is frequently inappropriate to have a ‘shot-gun’ response to tell patients to get off all their medications.

“The management team needs to … communicate what is going on with the patient and decide whether medications are appropriate … with the patient front and centre in that discussion!”

How to become a pain specialist

In Australia, six pain management specialists and 130 experienced pain physiotherapists work across various settings, from private practice to multi-disciplinary pain clinics.

These specialists are skilled in helping clients with complex and chronic pain problems that may not respond to traditional treatments, creating tailored programs that combine a biopsychosocial model of care.

Specialist pain physiotherapists have formal recognition of their expertise via a Fellowship of the Australian College of Physiotherapists.

The Australian College of Physiotherapists runs two-year specialist training programmes in the different disciplines of physiotherapy.