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Understanding Chronic Pain/Fibromyalgia
 
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Fibromyalgia: common cause of chronic pain

Over 90% of people with chronic musculoskeletal pain have fibromyalgia syndrome, although many other names are used to describe this condition. We use fibromyalgia as the name to describe a wide range of long lasting pain conditions.

Who gets it?
  • 1 to 2 % of the population has this condition at any one time.
  • It is more common in women than men in a ratio of 6:1.
  • The highest incidence is in people aged 20 to 40.
Features
  • Pain
  • Low pain threshold (tender points)
  • Poor quality sleep
  • Stiffness particularly in the morning
  • Fatigue
  • Emotional distress
Associated Symptoms
  • Pins and needles or tingling in the hands
  • Headaches
  • Irritable bowel symptoms
  • Swelling in the hands or elsewhere
  • Irritable bladder symptoms
  • Changes in the circulation, e.g. easy blueness of the fingers

Pain Sensitization
In fibromyalgia the pain nerves are too sensitive and we say that their pain threshold is lowered. Pressure and movement, previously not painful, become painful. Movement nerves start to initiate pain messages.

Physical Signs of Fibromyalgia

  • Overly sensitive tender points
  • The skin is abnormally sensitive to stroking, quickly producing a red line. (dermatographia)
  • Pinching a fold of skin produces considerable pain. (allodynia)
  • Grip strength can be diminished.

The Fibromyalgia Diagnosis
Concern about pain, fatigue, stiffness and other symptoms may drive people to see many doctors searching for a diagnosis and cure. Many doctors find no abnormalities and when fibromyalgia is diagnosed it can be a great relief. Pain sensitization, not tissue damage is responsible for the pain, but it can take time to understand what this means and how it should be managed. When you have the diagnosis, remember:

  • Your pain is real.
  • Your pain is due to pain sensitization.
  • You do not need to keep searching for another diagnosis.
  • You can learn to manage this yourself.

Causes of Fibromyalgia
Fibromyalgia can develop after:

  • An accident or injury
  • A virus or infection
  • Stress or trauma
  • No specific illness or injury

Fibromyalgia is not due to any abnormality in the muscles or joints; nor is it due to a psychiatric illness. There is a gross disorder of the pain system in fibromyalgia. It becomes sensitized with an elevation of substance P and a reduction in Serotonin. Stress appears to make the pain system more sensitive. You can read more about the development of fibromyalgia in the article
“How does chronic pain develop?”
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Pain Is Potent

Understanding your reaction to pain
Pain evolved as a signal to warn us of threat or damage. If we touch something hot, a reflex response of withdrawal occurs to protect us from further damage. Pain also alerts us to disease or pathology in the body. However, sometimes pain becomes chronic: it persists long after an injury should have healed and when no tissue damage or pathology can be identified. Sometimes a disease or degenerative changes has been identified, but the pain is greater than expected for the severity of the disease or degenerative changes. In both cases, our instinctive reaction to pain creates a real problem. If we react to chronic pain with the alarm nature intended for acute pain, unfortunately, we can amplify the pain signal. We say that the pain system is sensitized and pain is experienced at a higher level than expected for the injury or condition. The diagram below shows how pain sensitization is produced when pain is perceived as a threat.

A threat, whether real or imagined, elicits the stress response which prepares us to defend ourselves or flee from the threat. This primitive response worked well when the threat came in the form of a wild animal or angry neighbouring tribe. Once action was taken the body could then return to its normal level of activity. This response can still protect us in accidents and other life-threatening situations. However, if you keep responding to chronic pain as a threat, the pain sensitization will persist. To break out of this cycle you need to remove the threat by understanding your condition and knowing how to change the stress response.

Pain Causes Panic
A common reaction to pain is to panic. It is difficult to think straight and you may run for help, swallows pills, or stop everything (freeze). This is survival mode and underlying these reactions is fear. There are many things to fear because pain signals danger. You may be asking yourself these questions:

What’s wrong?
Have I got a serious illness?
Are they hiding something from me?
Can I handle it?
How long will it last?
Will I be able to work again?

Your Reaction
When there is a threat, an obvious reaction is to defend yourself and this involves fighting or resisting. Are you fighting your employer, insurance company, doctors, family or friends? The object/s of your anger and frustration can be many and varied. Perhaps you have resisted some treatments or explanations. While you feel threatened you may continue to fight or do the opposite and flee the situation. Perhaps you have withdrawn from life or particular activities and people. Some people escape by taking large amounts of medication or drinking alcohol. Not surprisingly, these strategies don’t work.
Pain Causes Chronic Stress
The pain itself causes stress but so to do all the consequences of having chronic pain such as conflict, uncertainty and physical limitations. Chronic stress affects many systems in the body including the muscular, gastro-intestinal and nervous systems. Many people wonder why they can’t concentrate and notice that their memory is poor. This can make it difficult to learn new coping strategies and to hear explanations for your chronic pain. Don’t underestimate the effects of stress.

Facing The Threat Without Defending Yourself
The solution is to learn a new way of dealing with the threat. Instead of reacting to the threat by fighting, fleeing, or freezing, you can learn to flow. This takes you out of the cycle of pain sensitisation. The “Path out of Pain” poster illustrates how you can change your relationship to the pain and become a self-manager instead of a victim. Click here to view the poster and read about a path out of pain.
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Chronic Pain Myths

These myths tend to keep you stuck: dispelling them can be an important part of your recovery. Your treating practitioners may also believe some of these myths and be advising you inappropriately. Read on to discover the myths that you believe and the consequences of believing them. The Self-Management program will help you realize the way that the myths limit your recovery and what you can do instead.

MYTH 1 You Have To Learn To Live With It
The first myth implies that recovery or progress is not possible and invariably leads to a sense of helplessness and hopelessness. Getting on with life is an important part of recovery and in this sense the statement is useful. However, you can do a great deal to improve the situation: you can find a path out of pain.
Consequence: Hopelessness and Helplessness

MYTH 2 Rest Cures Chronic Pain
Secondly, rest does not cure chronic pain and can be a recipe for disaster. Learning to balance rest and activity is fundamental to good management.
Consequence: Lack of fitness, stiffness, loss of function and more pain.

MYTH 3 Let Pain Be Your Guide
The third myth can also result in a steady decline in your functioning and fitness. Fear of the pain leads to protective responses such as stopping when it hurts. Pushing through the pain is not appropriate either. In fact, there is no satisfactory rule as you may need to push yourself sometimes and be gentle at other times.
Consequence: Fear of damaging yourself and loss of function and fitness.

MYTH 4 Hurt Is Harm
The fourth myth probably drives the third myth. It implies that pain is signalling damage and therefore pain should guide activities. When we realise that pain is a complex phenomenon involving physical and psychological factors we cannot assume that pain signals damage.
Consequence: Fear, inactivity and more pain.

MYTH 5 Real Pain Is Organic
Many practitioners believe that real pain has an organic origin (tissue damage or pathology) and if this organic origin cannot be established the pain is psychogenic ('in the mind'). It is most important to reassure you that your pain is real and results from a complex of interacting physical and psychological mechanisms.
Consequence: A need to prove that your pain is real.

MYTH 6 Search Long Enough And You Will Find The Cause And The Cure
The sixth myth prevents people in pain from getting on with helping and healing themselves. The search rarely, if ever, leads to establishing a single cause and simple cure.
Consequence: A desperate search and continual disappointment.

MYTH 7 Abnormal CT Scans Validate And Explain The Pain
Abnormal CT Scans do not necessarily explain the pain. Interestingly, studies have shown that up to 50% of asymptomatic people over 40 have abnormalities on their CT scans. Therefore, there is a high probability that an abnormal CT scan is not the explanation for the pain. Unfortunately failed surgery testifies to this. A focus on findings from CT scans can also misdirect management.
Consequence: Inappropriate management, fear and more pain.
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Chronic Pain and Compensation

When you are injured in the workplace or in an accident on the way to work, you enter a system. The employer and insurance company send you to doctors and other practitioners. Frequently you return to work on light or modified duties but you are not asked to take any responsibility for your recovery. The pie chart below illustrates how the responsibility is taken by the employer, insurance company and health care practitioners. The injured worker is not encouraged to take responsibility and becomes a victim of the system.

or

TREATING DOCTOR
provides
EMPLOYER
provides
INSURANCE COMPANY
pays for
Off-work certification
Restricted duties certification
Referrals to specialists
Referrals for treatment
Medication
Light duties
Rehabilitation
 Time-off work
Treatment
Investigations

A Shared Responsibility Model
To recover from soft-tissue injuries you must take responsibility for your own healing. Your employer, insurance company and treating practitioners can support you and provide suitable working conditions: the rest is up to you. The pie chart shows how the responsibility can be shared. The “Path out of Pain” course teaches you about self-management which involves you accepting responsibility for getting well. This can mean hard work and a willingness to change.

The Compensation Trap – Pain and disability are rewarded !

As you recover and move along this line from the left to the right, your benefits reduce. Unfortunately, this means that you have to take a risk to get well because there is no certainty of full recovery.

Beliefs can hinder or heal

Our beliefs are powerful: they determine how we feel and what we do. Some beliefs about pain create lots of suffering and make recovery from chronic pain very difficult. Other beliefs can relieve the suffering and help the process of recovery. Many people believe that they are at the mercy of their thoughts, that they can do nothing to control their minds. However, there are many ways to learn to control the mind. Ancient meditation techniques were developed to help people train their minds and create more peaceful and fulfilling lives. More modern psychological techniques such as cognitive-behaviour therapy can also help you change what you are thinking to change how you are feeling. The 2 tables below shows how changing self-defeating thoughts, to healing thoughts, can help you find your path out of pain.
Self-Defeating Thoughts Feelings
  1. I can’t do what I used to do.
  2. I will never get rid of the pain.
  3. I am useless.
  4. It’s all their fault.
  5. I must know what is causing the pain.
  6. I must be damaging myself when it hurts.
  7. I need someone to cure me.
  8. I have no control over my life.

Frustrated
Despairing
Worthless
Angry
Anxious
Scared
Helpless
Powerless

Healing Thoughts Feelings
  1. I notice what I can do.
  2. I am learning how to heal myself.
  3. Although there are things I can’t do, I am learning to acknowledge and appreciate who I am and what I can do.
  4. There are many factors causing my pain not just my job.
  5. I accept the explanation I have been given.
  6. I know that hurt is not harm with chronic pain.
  7. I am learning to take responsibility for my recovery.
  8. I am discovering ways to take charge of my life again.

Tolerant
Hopeful
Accepting

Peaceful
Relaxed
Confident
Responsible
Powerful

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Stressors with Chronic Pain

Sometimes people with chronic pain are reluctant to acknowledge that stress may be playing a part in their pain. They say that they are not stressed and that the pain is all physical, not psychological. Earlier in this section on understanding pain, we talked about a bio-psycho-social explanation for chronic pain. As you develop your understanding about fibromyalgia and chronic pain you will see the connection between these factors and pain sensitisation. Stress plays a big part in sensitising the pain system. When pain sensitisation is present, pressure and movement which previously did not cause pain, cause pain. In other words it can take very little to set off the pain nerves. Most importantly both physical and psychological stressors can set off the pain nerves.

Many people with chronic pain were living with high levels of stress before their injury or the development of the pain syndrome, but once chronic pain has developed, there are many more stressors. Check the list below and see how many of these apply to you.

  • The pain itself (tiring, relentless, unpleasant)
  • Repeated failures with treatment
  • Uncertainty about the future (finances, health, relationship)
  • Marital / Family disharmony
  • Disbelief from employers, co-workers, friends, family
  • Judgement by assessing doctors
  • Litigation / conciliation
  • Loss of quality of life
  • Loss of control

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Reactions to Pain

It is common for people to react to pain by trying to get rid of it or avoid it. They try different treatments, take painkillers, and stop moving because it hurts to move. This may provide some short-term pain relief, but, the diagram below shows how each reaction to the pain can lead to a trap.

Treatment Trap
Do you rely on treatment to keep you going? This is the treatment trap. Many people keep going to the physiotherapist, chiropractor or masseur hoping to be cured but they find that they become dependent on the treatment. Sometimes people keep going for treatment even when it hurts, or makes their pain worse. The treatment trap is a dead end because it doesn’t help you find a path out of pain. To get out of the treatment trap you will need to reduce your dependence on treatment and develop your self-management skills.

Medication Trap
Do you rush for painkillers when your pain increases? This is the medication trap. Unfortunately, your tolerance for painkillers increases the longer you take them and you will need more and more to get any effect. It is also common for many people to take painkillers even when they don’t help very much.

Rest Trap
Do you retire to bed when the pain gets bad? Have you stopped most of your activities? This is the rest trap. Perhaps you get some temporary relief from avoiding activity but there are better ways to get relief which will also assist your recovery from chronic pain.

Diagnostic Trekking Trap
How many doctors and other practitioners have you seen? You could be in the diagnostic trekking trap, or well on the way. If you accept the explanation in this section, you could stop diagnostic trekking and begin to learn self-management instead ?
People caught in these traps often get worse, instead of getting better, and become dependent on their treating practitioners. Because they are able to do less and less, they begin to feel increasingly helpless and hopeless.

As each approach fails to provide the answer, the person in pain becomes more depressed. While they keep searching for the cause they remain alert and their anxiety level is high. Chronic depression and chronic anxiety result.


Reactions to pain amplify the pain

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Pain and Personality

Pain Prone People
It seems that some people have a greater risk of developing chronic pain. It is very common for people with fibromyalgia or other chronic pain syndromes to have some or all of these characteristics.

  • Compulsively busy
  • Perfectionistic
  • All or None responses
  • Easily hurt
  • Tendency to worry
  • Repress feelings
  • Sensitive
  • Self-reliant
  • Self-sacrificing
  • Poor self-care

You believe that you have to cope with whatever happens in life. You keep going long after others would have stopped or asked for help. You keep shouldering the load even though your body is cracking up. Others see you as a coper and keep asking you to do things for them. You have convinced everyone, including yourself, that you can cope with everything.
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