Persistent Pain

Understanding Your Pain

Pain is a very important normal protective response to threat or potential threat. It is the brain’s way of ringing the alarm to signal danger.

Pain experience is guided by many factors feeding into the brain:

Physical Injury

After injury, tissue damage triggers an inflammatory response (acute), which then activates the brain processes to promote healing and this involves firing off danger sensors, which increase nerve sensitivity to protect from further injury.

Psychological Issues

Negative emotions such as anger, stress, frustration or low mood, may increase your pain experience. For example anger at being injured in a motor vehicle accident especially when it wasn’t your fault, feeling there is no support at work while injured and not being able to do your normal job, disappointment at not being able to attend social functions or frustration at missing sport. Especially if injury drags on, these psychological issues become a greater factor and impact on your pain experience often heightening your symptoms. On the other hand, the brain can act to decrease the pain experience and in times where there is immediate danger it can inhibit pain so you can function to get to safety.

Tissue Healing

Injured tissues such as bones, discs, ligaments and muscles have reasonably defined healing time (days/weeks). At the initial time of injury, your body will try to protect it from further damage and the pain is at its worst. After a few days/weeks post injury, your body will lay down new tissue and reduce the need to protect your injury and therefore the pain will significantly lessen. However, some pain persists beyond tissue healing time. “In this situation, the brain concludes that a threat remains and that you need all the protection you can get” (Butler & Moseley, 2013).

Chronic or Persistent Pain

If pain persists the danger alarm system can become progressively more sensitive and active (increase chemicals are released in the brain and nervous system). As the response system becomes more involved it starts contributing to the problem. Altered brain alarms or danger sensors causes increased pain experience “central sensitization”.
The features of chronic or persistent pain (central sensitization) are:
  • Areas that used to hurt, now hurt more “hyperalgesia”
  • Things that didn’t hurt before, now hurt “allodynia”, for example when you stretch a muscle previously the brain understood the muscle was being stretched but now the brain interprets the same experience as pain, even light touch can cause danger messages to be sent to and registered in the brain as pain.
  • Remember that the pain is real but the processes behind it are no longer driven by tissue damage but by the altered response of the nervous system. The brain is being told that there is more danger at the tissues than there actually is.

The Downward Spiral

The brain adapts and changes and learns to be very good at protecting you from anything that might be dangerous to your tissues – the pain typically persists, spreads, gets worse and more simple movements hurt and more “emotional” upsets even minor ones can increase your pain.

Key Things:

  • Amount of pain you feel does not necessarily relate to or indicate the amount of tissue damage, for example a paper cut can hurt a great deal.
  • Amount of degeneration or damage seen on x-ray, MRI or ultrasound does not necessarily indicate pain experience. Some changes can be ‘normal’ age related changes and in fact are not the cause of the pain being experienced.
  • Signs of pathology on x-ray does not mean your pain won’t settle and lack of findings does not mean your pain is not real, it is.
  • Anyone can develop chronic pain. Persistent pain is not a normal part of ageing and treatment for it should be sought.
  • Early intensive treatment of sudden and severe pain may reduce the odds of it developing into chronic pain (metronicneuro, 2017)


Butler, D., & Moseley, G. Lorimer. (2013). Explain pain (Second ed.) Metronicneuro. (2017). www.medtronicneuro.com.au Precisionascend. (2015). Explaining pain. Retrieved from http://www.precisionascend.com.au/index.html

Management of Your Persistent Pain

Education and understanding pain are critical for you to overcome your pain and return to a fulfilling life. It is now known that understanding more about why things hurt can help people to overcome their pain, by giving them the knowledge to take control and challenge their pain.

An important part of you taking control is having an active and central role in your management. Hampton Park Physio’s concept of self-management is that you the patient is empowered to make decisions regarding the treatment and self-management strategies that most assist you optimize your ability to manage your condition.

The Upward Spiral

Exercise and increased activity over time can be used to overcome the “downward spiral”. The “upward spiral” illustrates the steps involved and the benefits that will come when you persist with a well-designed exercise program.

Things that can help you take control


Standing Think tall, chest lifted, shoulders relaxed, chin tucked in and head level. Posture should be stable, balanced and relaxed. Sitting Don’t stay seated too long, ideally no more than 20 minutes. Stand up, stretch and move around. Sit tall with your back supported, and ensure your workstation or computer are correctly positioned.


Important Points to Remember For Success with Your Exercise Program:
  • Accept that an exercise program is unlikely to take away/’cure” your persistent pain but it can help you do more and feel better than if you don’t keep active. Research shows that the more exercise an injured person performs the less pain behaviours that they exhibit. (Monagle 2016)
  • Understand that it is normal to feel pain as you start to exercise parts of your body that have become stiff or weak or deconditioned.
  • Understand that in persistent pain “hurting” does not equate to “harming”
  • Utilise relaxation strategies while you are exercising to help reduce the sensitivity of the nervous system such as controlled breathing, rather than “guarding”, breath holding or grimacing.
  • Personalise your exercise program around activity goals that are important to you to help keep you motivated. You will need patience and perseverance with your exercise program to realise the benefits.
  • Set yourself realistic achievable short-term goals, which relate to flexibility, strength, fitness and function.
  • You need to establish a baseline level of exercise that you can manage and progress from that point, with a pacing & graded approach similar to a “training” program.
  • Your physiotherapist can greatly assist with this essential component of management, by helping to develop an individualized exercise program including stretches, strengthening, fitness/conditioning work, and activity specific exercises related to your home and work functional requirements.
  • You may have setbacks from time to time. This is to be expected, so don’t let it discourage you.


Medication is often an important part of your management. A key role of medication is to reduce your pain to allow you to increase your activities and exercises enabling you to regain function. (Monagle 2016). It is essential that you understand what each medication is for and when you are best to take it. If you are unsure, you need to discuss this with your GP.

Modify your movements

Relearning & modifying movement and activity to reduce stresses, for example if bending hurts try to modify activity by:
  • Altered start position to decrease the effects of gravity
  • Virtual movement, imagining yourself doing the activity
  • Fun activity incorporating movement
  • Water versus land to reduce effects of weight bearing
  • Practice components with support
  • “sliders” to decrease tension on the nervous system and surrounding joints & muscles


  • It is important that you can recognize the warning signs that you are over doing things so you can back off and avoid a flare up.
  • Find ways to relax, for example music, relaxed breathing or mediation as this can help reduce stress and assist you to lessen your pain and improve your sleep.
  • Ice packs, hotpacks, spikey ball into muscle trigger points, TENs and gentle exercises/stretches can all help you manage your pain. Your physio can help guide you but you need to work out what helps you the best.
  • Muscles, joints and your nervous system need to stay active to remain healthy and responsive. Avoid prolonged sitting and static postures greater than 30 minutes. Movement switches on other body systems as well including your metabolism, cardiovascular system and stimulates chemical reactions throughout the body.

The Role of Physiotherapy

Focus on working out what factors are playing a predominant role in each individual patients and then try to address them. (Stirling 2013).
  • Your physiotherapist can play a central role in developing and helping you to implement an individualized exercise program, which is specific and appropriate for you.
  • Health coaching to assist you improve your understanding how your lifestyle choices influence your health and how healthier options can have a very positive effect on your persistent pain.
  • Physiotherapy can involve passive “hands on” treatment such as joint mobilization/manipulation, soft tissue massage or dry needling to help decrease your pain to enable you to move better, making it easier for you to increase your exercise and activity level. While the effect of passive treatment is short term pain relief the real benefit is getting you able to move and function better, and improve your ability to engage in home and work activities, for example increase your work duties or hours.
  • Throughout your physiotherapy program it is important to take measurements to assess whether you are improving and determine if continued physiotherapy is the optimal treatment approach for you. Such measurements include questionnaires, functional gains such as increased activity tolerance, and/or increased work hours or duties.

Psychological Support

  • Pain can have a profound social and psychological impact on the people it affects. Talking to a professional counsellor or psychologist can help with negative effects that pain may have on your mobility, social interactions, and relationships.
  • Chronic pain can be extremely stressful in the way it affects your relationships, work or ability to take part in daily activities. Psychologists, psychiatrists and counsellors work with pain patients on many levels – from relationship techniques to coping and self-monitoring skills.
  • Talking about your pain and its impacts can often help you and your loved ones to understand its various effects.

Work as part of treatment

  • Studies have shown that to remain at work (in some capacity) or return to work as soon as possible following an injury helps the recovery process. Getting back to work is a very important outcome for a person with persistent pain. There is strong research that being unemployed has serious negative health consequences (Daly, 2013).
  • Your Physiotherapist & Doctor have an important role to assist you & your work develop suitable duties and hours of work and guide the progression of these duties.
  • Return to work can decrease isolation and gives purpose. It promotes an increased focus on functional activity rather than sitting at home thinking about the pain.
Other Lifestyle Factors


It is well recognized that lack of exercise and poor diet can lead to weight gain which can worsen an individual’s pain experience and lead to feeling depressed. There is a strong link between the physical pain being experienced and the mental health struggles that accompanies. There is mounting evidence that our immune system plays a central role in depression and other mental health problems. (Jacka 2017). "We're increasingly understanding that the gut and its resident microbiome has a leading role in prompting immune function and is very much involved in brain health. Diet and nutrition are as relevant to brain and mental health as they are to physical health.” Jacka says. This all highlights the importance of maintaining a good balanced diet to aid your recovery by providing the fuel you need to exercise and increase activity while avoiding weight gain and at the same time improving your mood and general alertness. Referral to a Dietician may be indicated to help you understand the changes you need to make to your diet.


Persistent pain is generally accompanied by increasing anxiety and fear which in turn can lead to increasing sleep disturbance which further heightens the pain experience resulting in a vicious circle. (Monagle 2016) It is important to try and establish a regular sleep pattern. The use of relaxation techniques such as relaxed breathing, hotpacks and/or medication may assist you to develop a better sleep pattern. Sleeping well can help lift your mood, give you more energy to exercise and engage in activity and assist you to cope better with your pain.

Things to avoid

  • Typically one of two things occur: people will avoid activities that cause any aggravation or their pain; or two, ignore the pain and push on with the activities regardless, only to suffer a flare up in their pain later and eventually needing to rest to recover. This is called the “boom and bust cycle”
  • Prolonged bed rest is to be avoided as is spending excessive time slouching on the couch.
  • Repetitive movements that you know can cause your symptoms to increase need to be limited.
  • Lifestyle factors such as smoking, excessive alcohol intake and poor diet all impact negatively on the body’s healing ability.

There are many things you can do to improve quality of life.
Aim to take control of your life.


Daly, A. (2013). Guiding Compensable Clients Out of Pain. Intouch, 1, pp 15-17 Medtronicneuro. (2017). Psychological Support. Retrieved from http://www.medtronicneuro.com.au Precisionascend. (2015). Explaining pain. Retrieved from http://www.precisionascend.com.au/index.html https://www.blackdoginstitute.org.au/get-involved/exercise-your-mood http://www.theage.com.au/lifestyle/health-and-wellbeing/your-mental-health-involves-your-whole-body-and-starts-with-diet-20170912-gyfq4b.html