Chronic Pain: What it is, and what can you do about it?

Pain is something that we all experience, and it can start after an injury, during an illness, following surgery, or even without an obvious cause. Indeed, pain is not always related to body damage, like a muscle tear or a broken bone.

In support of this, to better understand pain, modern science shows us that pain is a complex experience produced by the nervous system. It is influenced by information coming from the body, but also by previous experiences, expectations, emotions, stress, sleep and the context in which the pain occurs.

The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. What we have to understand, to start with, is that pain can occur even when there is little or no ongoing tissue damage.

That’s really important when we talk about chronic pain.

What is chronic pain?

By definition, chronic pain is described as pain that persists or recurs for more than three months. That said, this doesn’t mean that an injury has remained damaged for such a long time. In fact, in some people, pain initially begins because of an injury or another physical problem but continues after the original tissue has had enough time to heal.

This is where chronic pain can develop, because the nervous system has become more sensitive to signals from the body. So yes, even after such a long time and with physical damage repaired, the nervous system is still in alert mode, creating a signal of pain, where actually nothing physical npothing is wrong.

This is one reason why treating chronic pain is often more complicated than simply finding a damaged muscle, tendon or joint and treating that structure.

Chronic pain can involve different mechanisms, including nociceptive, neuropathic and nociplastic pain, and more than one mechanism can be present at the same time.

Pain does not always equal damage

When I treat patients who suffer from chronic pain, including pain that recurs after years, I have to ensure I explain how pain actually works, and that pain and tissue damage are not always directly proportional.

Indeed, we are all aware that we all have different pain tolerance, and that someone can have significant pain with relatively little tissue damage, while another person can have substantial structural changes with surprisingly little pain.

This does not mean that the pain is imaginary, or that you have to feel crazy to be in constant pain.

Unfortunately, the pain is real.

But what this means is that we need to create a management program to change how your nervous system is dealing with pain management and response.

Because at the base of it all is that when pain persists for a long time, the sensitivity of the pain system can change. This can contribute to increased sensitivity to pressure, movement or other normally tolerable stimuli. It is like an alarm that went on every day for weeks, and then months, and out of nowhere, any stimulus can trigger it.

So yes, this is one of the reasons why chronic pain needs to be approached as more than a local problem in a muscle or joint.

Why can pain continue after an injury has healed?

After an initial injury, or a nociceptive stimulus, pain can hang around even when no stimulus of major level is left.

A stimulus that could give you pain is getting spiked with a needle, for example, when doing a blood test. If that same experience is then associated with a major stressor, like a trauma- think of pain that started after a severe car accident- the pain can be more challenging, because your central nervous system is now associating the pain not only with a physical injury (a needle penetrating the skin) but to a severe car accident.

That trauma, that intense experience, can now wire your nervous system to be in alert mode constantly and therefore constantly fire a pain response, even though the physical damage is repaired.

Other factors can also influence pain processing, including:

• Higher level of stress
• Poor sleep
• Previous pain experiences
• Fear of movement
• Expectations about what a particular movement might do to the body.

So yes, you now can also understand that avoiding movement completely is not always the best long-term solution, because that fear of movement can increase the pain expectation and experience.

Can hands-on treatment help chronic pain?

This is another topic I find myself sharing constantly with my clients.

Hands-on treatment, yes, is extremely helpful with chronic pain, and here is why.

Manual therapy, that is, Remedial Massage or MLD, can provide a strong sensory input to the nervous system.

Any form of touch therapy, indeed, is simply a stimulation to the nervous system. The trust built with my clients and the nervous system touch stimulation create a positive cycle that can help modulate the pain response for the better.

In more detail, touch, pressure and movement stimulate sensory receptors and provide the brain with new information about the area being treated. This can influence how pain is processed and may temporarily reduce pain sensitivity.

A systematic review and meta-analysis of physical therapy interventions in people with chronic musculoskeletal pain found improvements in some measures associated with pain processing, including temporal summation and conditioned pain modulation. The authors concluded that physical therapy may have a modest effect on altered pain processing, although the results differed between treatment approaches.

But even if science backed up the benefit of hands-on treatment for chronic pain, we have to remember that massage can only provide pain modulation, and no one, with their hands, can actually fix a problem or heal you. And I can stress this enough to my clients. In fact, I always explain to them that I see hands-on treatment as one part of a broader treatment plan, rather than the entire solution.

The temporary reduction in pain can be useful because it may make it easier for someone to move, exercise and gradually rebuild confidence in the painful area.

Why is exercise important for chronic pain?

Exercise is a form of self-healing that works best for acute and chronic pain, not only because it would make you stronger or more mobile, but because it can also influence the way the nervous system processes pain.

Indeed, the idea of fixing pain comes down to making your body, or even better, your nervous system, adapt to load. And in order to do so, you have to periodically (3 to 5 times a week) load that structure.

This is what exercise is about.

So, rather than constantly protecting an area from movement, we can progressively teach the body that movement and loading are tolerable.

Exercise can also change how we respond to pain

IF you ever experienced pain for a prolonged period of time, you may have started avoiding using that body part to avoid being in pain.

This attitude can create a difficult cycle:

Pain → fear of movement → less movement → reduced capacity → more sensitivity to loading → more pain.

Exercise can help break this cycle.

A systematic review by Smith et al. (2017) of exercise training and fear-avoidance found that exercise may reduce fear-avoidance, particularly in people with low back pain, although the certainty of evidence was low.

Therefore, I don’t simply prescribe exercise because “you need to get stronger”, but to help you break through the fear of movement. And sure, the exercise needs to be appropriate for your current load capacity, and not just pushing you beyond your capacity.

The objective is to gradually increase what the body can tolerate.

Is it normal to experience pain after exercise?

Yes, it is, but that pain doesn’t have to stop you from moving.

So what I always suggest to my clients is to compare the pain post-exercise to the worst pain they have ever experienced in the injured area.

Let’s look at this example:

Worst pain in the back in the acute injury phase was 9/10.

A few days or even a week have passed since this injury episode, and we are now starting to do exercises for recovery.

If, after exercise, back pain is 4/10, that is an acceptable level.

Why?

Well, that 4/10 is telling us that we engaged the structure we focus on too, but we didn’t aggravate the pain to the worst level it ever experienced.

The nervous system is then adapting the load to a minimal pain response. Now, as days/weeks pass by, we can keep increasing the load and aim to maintain the pain response low at 4/10 or lower.

This is basically a controlled inflammatory response which would contribute to tissue repair and adaptation.

However, more inflammation does not automatically mean more recovery; that’s why, once we reach our reps*sets goal, we let the body rest to recover.

And this is an important distinction, as the rehabilitation’s goal is not to deliberately damage tissue or create as much inflammation as possible.

Instead, I want to provide the body with an appropriate amount of stimulus so that it can adapt.

How do I know if the pain I am experiencing is just enough?

If you are having trouble understanding what type of pain you can reach during the recovery exercises, here is a clinical loading guideline rather than a universal medical rule.

The important question is not simply:

“Did it hurt?”

The better questions are:

• How much did it hurt?
• How did the pain behave during the exercise?
• How did it feel afterwards?
• Did the symptoms settle?
• Could the person perform their normal activities?
• Are we gradually improving their strength, movement and tolerance?

The answer to these questions helps determine whether the exercise dose is appropriate.

We don’t need to avoid every painful movement

So, as mentioned above, when someone suffers from chronic pain, it may start associating pain with danger.

Therefore, if every painful movement is interpreted as “I am damaging myself”, it can become tempting to avoid that movement altogether. But again, pain does not always mean that tissue is being damaged. Pain is a brain/alarm response. That’s where controlled exposure to movement and load can help you regain confidence and capacity.

So yes, this is where the 4/10 pain plays a role. You don’t need to push through severe pain.

That’s where there is a significant difference between controlled, tolerable discomfort and pain that is escalating, severe, unexpected or accompanied by other concerning symptoms.

Exercise should be progressed according to your presentation, history, goals and current capacity. And the goals have to be realistic, following what the body’s healing capacity is, and not what we want.

Hands-on treatment and exercise work better together

Ok now we can put the picture together and analyse how the combination of hands-on treatment and exercise becomes particularly useful.

Hands-on treatment can sometimes provide a short-term reduction in pain and improve how comfortable a person feels moving.

Exercise then gives us the opportunity to use that improved tolerance.

For example:

Hands-on treatment → reduced sensitivity → easier movement → exercise → increased capacity → greater confidence → improved tolerance to load.

Over time, the objective is not for someone to need treatment every time pain appears, but the objective is to improve their ability to manage movement, load and everyday activities themselves.

This is why I often combine hands-on treatment with exercises rather than relying on massage or manual treatment alone.

What about chronic pain that keeps coming back?

So, Chronic pain does not always disappear in a straight line; indeed, there can be good days and bad days.

Someone can improve for several weeks and then experience a flare-up after increased activity, poor sleep, stress, illness, or simply doing more than their current capacity allows. But a flare-up does not necessarily mean that the original injury has returned; it is more an indication that the current load temporarily exceeded the person’s capacity.

And to stop this from reappearing, we want to adapt the load once again to a lighter one, and not stop moving completely.

Adjusting the load allows symptoms to settle and then progressively rebuild capacity.

In fact, rehabilitation is about building capacity rather than chasing or avoiding pain.

What can you do about chronic pain?

There is no single treatment that works for every person with chronic pain.

A good starting point is to understand what may be contributing to the pain and then develop a treatment plan around the individual.

Depending on the presentation, this may include:

• hands-on treatment to help modulate pain and improve movement tolerance
• progressive strengthening
• mobility exercises
• graded exposure to movements that have become difficult or threatening
• improving general physical activity
• education about pain and tissue loading
• improving sleep and recovery
• managing training and workload
• addressing factors that may be contributing to repeated flare-ups
• referral to another health professional when further assessment is required, like a scan

Along with all those factors, we can certainly say that exercise and physical rehabilitation are particularly important because they can address more than the immediate pain response.

They can help improve strength, physical capacity, confidence and the ability to perform everyday activities.

Pain does not have to control your movement

In conclusion to this blog, I want to make sure that we are all on the same page with the understanding that living with chronic pain can make movement feel threatening. But again, pain is not always a direct measurement of damage.

And understanding this does not mean ignoring pain, but it means learning to interpret it differently.

As a Clinical Myotherapist who treats a broad range of pain and injuries, I would assess your presentation, understand your history and goals, use hands-on treatment when appropriate, and help you progressively move and load your body.

The aim is not simply:

“How can we make the pain disappear today?”

It is also:

“How can we help your body tolerate more tomorrow?”

For many people with persistent musculoskeletal pain, that change in approach can be an important part of moving from constantly protecting the painful area to gradually rebuilding confidence, capacity and function.

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